HEALTH  SCIENCES  STANDARD 


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VOLUME  I 
CLINICAL  TUBERCULOSIS 


CLINICAL  TUBERCULOSIS 


BY 

FKANCIS   MARION  POTTENGER,   A.M.,   M.D.,   LL.D. 

MEDICAL   DIRECTOR,    POTTENGER    SANATORIUM    FOR   DISEASES    OF    THE   LUNGS   AND 

THROAT,   MONROVIA,    CALIFORNIA;    PROFESSOR    OF   DISEASES    OF    THE 

CHEST,    COLLEGE    OF    PHYSICIANS    AND    SURGEONS,    MEDICAL 

DEPARTMENT,  UNIVERSITY  OF  SOUTHERN  CALIFORNIA, 

LOS  ANGELES,   CALIFORNIA. 


WITH  A  CHAPTER  ON  LABORATORY  METHODS 

BY 
JOSEPH  ELBERT  POTTENGER,  A.B.,  M.D. 

ASSISTANT    MEDICAL    DIRECTOR,    AND    DIRECTOR    OF    THE    LABORATORY,    POTTENGER 

SANATORIUM    FOR    DISEASES    OF    THE    LUNGS    AND    THROAT, 

MONROVIA,  CALIFORNIA. 


VOLUME  I 

PATHOLOGICAL   ANATOMY,   PATHOLOGICAL   PHYSIOL- 
OGY, DIAGNOSIS,  AND  PROGNOSIS 


WITH  ONE  HUNDRED  AND  FIVE  TEXT  ILLUSTRATIONS  AND 
CHARTS,  AND  SIX  PLATES  IN  COLORS 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1917 


Copyright,  1917,  by  The  C.  V.  Mosby  Company. 


Press  of 
The  C.  V.  Mosby  Company 
St.  Louis 


TO 

SIR  JAMES  MACKENZIE,  LUDOLF  KREHL,  AND 
GEORGE  W.  CRILE 

Clinicians  who  Typify  that  Growing  Spirit  in  Internal  Medicine  which 

Kecognizes  the  Importance  of  the  Study  of  Pathological 

Physiology  and  Emphasizes  its  Application, 

THIS  WORK  IS  DEDICATED 

By  the  Author. 


INTRODUCTION 


During  recent  years  medical  literature  has  abounded  in  papers 
and  books  treating  of  the  subject,  tuberculosis.  Many  of  these 
contributions  have  been  excellent.  The  majority  of  them,  how- 
ever, have  been  written  from  a  viewpoint  which  is  entirely  too 
narrow.  If  we  are  to  make  advances  in  our  knowledge  of  tuber- 
culosis we  must  take  a  broader  view  than  that  expressed  by  the 
prevalent  idea,  that  tuberculosis  is  a  disease  due  to  the  tubercle 
bacillus,  which  produces  a  group  of  tubercles  in  the  lung,  and 
that  its  cure  comes  about  as  a  result  of  good  food  and  open  air. 
We  must  look  upon  it  as  being  an  infectious  disease  producing 
inflammatory  processes  in  some  organ,  or  organs,  of  the  body, 
but  indirectly  influencing  every  organ  and  cell  of  the  body; 
and  prior  to  the  time  that  a  specific  cure  has  been  found,  we 
must  look  upon  treatment  as  being  the  application  of  a  sufficient 
number  of  remedies  and  measures  to  raise  the  patient's  defensive 
powers  sufficiently  high  to  destroy  the  tubercle  bacilli  and  to 
furnish  the  focal  stimulation  necessary  to  hasten  scar  formation. 
It  is  from  this  standpoint  that  I  have  approached  my  subject. 
Anatomy  and  physiology,  both  normal  and  pathological,  have 
been  made  the  basis  of  my  studies;  and  visceral  neurology  has 
received  unusual  attention.  I  have  endeavored  to  approach  the 
study  of  tuberculosis  from  the  standpoint  of  internal  medicine 
in  its  broadest  sense. 

I  am  endeavoring  to  present  in  this  monograph  a  record  of  the 
observations  which  I  have  made  during  twenty  years  of  clin- 
ical study.  The  studies,  for  the  most  part,  have  been  made  on 
patients  in  the  Pottenger  Sanatorium  for  Diseases  of  the  Lungs 
and  Throat,  Monrovia,  California.  My  patients  have  represented 
all  stages  and  phases  of  the  disease.  For  the  most  part,  they 
have  been  suffering  from  advanced  widespread  lesions.  They 
have  been  of  an  unusually  intelligent  class,  and  this  has  added 
greatly  to  the  opportunity  for  careful  study. 

In  my  discussion  of  the  pathological  problems  I  have  en- 
deavored to  make  the  presentation  as  practicable  as  possible. 


10  INTRODUCTION 

My  viewpoint  is  that  of  a  clinician.  While  I  have  in  no  manner 
ignored  the  subject  of  cellular  pathology,  I  have  borne  in  mind 
and  discussed  more  extensively  that  side  of  pathology  which  is 
of  greater  importance  to  the  clinician,  namely,  functional  pathol- 
ogy. Scientific  medicine  is  just  beginning  to  appreciate  the  im- 
portance of  this  study.  In  the  past,  functional  disorders  were 
considered  as  being  of  little  concern  and  not  worthy  of  legitimate 
study;  but,  as  our  knowledge  of  visceral  neurology  and  biochem- 
istry increases,  we,  as  clinicians,  are  learning  that  we  should  give 
as  much,  if  not  more  attention  to  functional  derangements  than 
to  actual  organic  diseases. 

I  have  discussed  the  nervous  system  more  extensively  than  is 
usual  in  a  work  of  this  kind,  and  have  particularly  emphasized 
the  importance  of  understanding  the  relationship  of  the  vegeta- 
tive nervous  system  to  disease.  I  have  endeavored  to  indicate 
the  important  part  that  it  plays  both  in  being  acted  upon  by  the 
disease  and  its  products,  and  in  influencing  the  cellular  activity 
in  other  organs  and  cells  when  so  acted  upon.  While  my  discus- 
sion of  this  subject  is  necessarily  more  or  less  unsatisfactory  be- 
cause of  the  many  gaps  in  our  knowledge,  yet  I  have  endeavored 
to  make  my  treatment  sufficiently  complete  to  give  those  who 
have  not  had  their  attention  directed  to  the  importance  of  vis- 
ceral neurology  a  working  basis  for  further  study  in  this  field  of 
investigation. 

The  study  of  phthisio genesis  is  discussed  from  the  standpoint 
of  tuberculous  infection  as  a  condition  of  childhood,  from  which 
clinical  tuberculosis  in  the  adult  is  a  metastasis  occurring  after 
the  early  infection  has  changed  the  reactivity  of  the  body  cells 
and  endowed  them  with  the  power  of  producing  specific  defensive 
ferments.  The  influence  of  this  specific  defense  in  warding  off 
further  infections  and  in  changing  the  course  of  the  disease  by 
making  it  more  chronic  when  implantation  has  occurred;  like- 
wise its  influence  upon  the  practical  problems  of  prophylaxis, 
are  carefully  considered. 

The  subject  of  fever  has  received  careful  consideration  and  its 
relationship  to  the  nervous  system  has  been  strongly  empha- 
sized. Anaphylaxis  has  been  considered  in  its  relationship  to 
the  greater  vagus  division  of  the  vegetative  nervous  system. 

The  power  of  the  body  to  adjust  itself  to  new  and  changed  con- 


INTRODUCTION  11 

ditions  has  received  careful  attention.  Such  compensatory- 
changes  as  occur  between  the  two  sides  of  the  thorax;  between 
the  thorax  and  abdomen;  and  those  which  take  place  in  the  cir- 
culatory system,  have  received  far  more  attention  than  is  or- 
dinarily given  them. 

The  chapters  on  diagnosis,  as  well  as  those  on  therapy,  are 
treated  in  their  relationship  to  physiology  and  functional  pathol- 
ogy. 

The  etiological  classification  of  symptoms  will  be  welcomed  as 
an  important  advance  which  simplifies  the  picture  of  clinical 
tuberculosis  and  aids  in  its  understanding. 

Physical  examination  is  considered  in  the  light  of  my  studies  of 
the  changes  in  the  musculature  and  other  superficial  tissues  as 
produced  reflexly  by  the  inflammatory  processes  in  the  lungs. 
The  importance  of  inspection  and  palpation  is  emphasized;  and 
these  methods  of  examination,  probably  for  the  first  time,  are  given 
their  full  value  in  diagnosis.  Percussion  and  auscultation  are 
described  not  only  in  relationship' to  the  pathological  process  in 
the  lung,  but  in  relationship  to  all  other  changes  in  the  organs 
within  the  thorax,  as  well  as  to  the  changes  wrought  in  the 
muscles  and  subcutaneous  tissues  by  the  reflex  motor  and  trophic 
impulses  produced  by  the  pulmonary  inflammation.  This  new 
point  of  view  offers  an  explanation  of  many  of  the  errors  which 
have  always  attended  these  methods  of  examination. 

I  have  endeavored  to  look  upon  the  therapy  of  tuberculosis 
from  a  common  sense  viewpoint.  Realizing  that  the  most  im- 
portant factors  in  the  cure  of  tuberculosis  are  intelligent  medi- 
cal guidance  and  faithful  co-operation  of  the  patient,  these 
points  have  been  everywhere  emphasized  throughout  this  work. 
I  have  endeavored  to  explain  the  physiological  basis  of  the  ac- 
tion of  the  more  important  measures  employed  in  treatment,  in 
the  hope  that  such  an  understanding  will  produce  a  more  intel- 
ligent therapy  than  that  which  is  practiced  today.  Not  only  have 
I  pointed  out  the  benefit  to  be  derived  from  each  of  our  more 
important  measures;  but,  at  the  same  time,  have  shown  their 
limitations. 

Psychotherapy  is  given  an  important  place  in  therapeutics, 
and  an  attempt  has  been  made  to  show  the  physiological  basis 


12  INTRODUCTION 

of  its  action  in,  the  hope  that  it  will  find  a  wider  application  in 
practice. 

The  discussion  of  laboratory  diagnosis  is  not  intended  to  be 
a  restatement  of  the  ordinary  routine  methods  which  are  em- 
ployed in  the  examination  of  laboratory  specimens,  but  a  discus- 
sion looking  towards  more  accurate  methods  and  more  valuable 
studies  resulting  from  a  critical  study  of  laboratory  specimens. 
This  chapter  is  written  by  Doctor  J.  E.  Pottenger,  who  has  made 
the  laboratory  study  of  the  patients  in  the  Pottenger  Sanatorium 
for  the  past  eight  years. 

In  the  tuberculosis  clinic  I  have  endeavored  to  give  to  those 
who  are  interested,  but  less  familiar  with  the  course  of  chronic 
tuberculosis,  a  definite  picture  of  this  disease  through  a  discus- 
sion of  individual  cases  which  have  been  under  the  writer's  care. 
In  this  I  endeavor  to  teach  the  early  symptomatology;  to  show 
the  mistakes  in  diagnosis;  and,  by  following  the  case  during  its 
progress,  to  show  the  relationship  between  symptomatology  and 
the  pathological  changes  which  are  going  on  within  the  tuber- 
culous process.  While  I  realize  that  the  temperature  and  pulse 
curves  do  not  indicate  fully  the  character  of  the  pathological 
lesions  within,  yet  I  have  used  them  to  furnish  a  tangible  meas- 
ure of  the  toxemia  present.  When  necessary,  I  add  other  im- 
portant symptoms  to  make  the  picture  clearer.  I  have  attempted 
this  in  order  to  answer  the  many  inquiries  which  I  receive  from 
men  asking  if  such  and  such  a  case  is  not  being  harmed  by  some 
remedy  or  measure  that  is  being  used,  or  if  some  other  remedy  or 
measure  will  not  benefit  more.  I  wish  to  impress  the  fact  that 
chronic  tuberculosis  is  a  disease  which  runs  an  uneven  course 
and  in  which  many  periods  of  activity  must  be  expected  before 
a  final  result  is  attained ;  and  show  that  these  periods  of  activity 
are  natural,  and  that  they  do  not  indicate  that  the  patient  is  not 
improving  satisfactorily. 

The  burden  of  my  study  in  tuberculosis  has  been  to  find  an  ex- 
planation for  the  facts  observed, — the  reason  why.  I  have  made 
no  effort  to  treat  the  subject  in  textbook  style.  The  work 
should  be  looked  upon  as  a  series  of  monographs  dealing  with  the 
subjects  under  discussion  in  a  more  or  less  complete  manner. 
This  has  made  a  certain  amount  of  repetition  necessary,  but,  had 
it  been  omitted,  it  would  have  been  to  sacrifice  the  continuity  of 


INTRODUCTION  13 

thought.  Throughout  I  have  endeavored  to  make  my  discussions 
practical.  I  have  endeavored  to  correlate  the  pathology  with  the 
symptomatology,  so  that  the  reader  will  think  of  symptoms  as 
being  an  expression  of  functional  disturbance  caused  by  patho- 
logical change;  and  have  attempted  to  classify  the  symptoms  so 
as  to  aid  in  locating  the  pathological  process. 

While  much  that  I  have  written  is  incomplete,  I  trust  that  it 
will  emphasize  the  importance  of  a  study  of  this  kind  and  stimu- 
late others  to  pursue  it  further. 

I  have  made  no  attempt  to  give  an  historical  statement  of  the 
subject,  nor  have  I  attempted  to  review  the  excellent  works  of 
many  observers.  I  have  quoted  freely,  where  the  quotation  added 
to  my  argument,  or  elucidated  some  point  under  discussion.  The 
names  of  many  excellent  workers  whose  studies  have  added  to 
the  richness  of  our  knowledge,  and  who  have  both  consciously 
and  unconsciously  influenced  my  conclusions  will  not  appear  in 
the  text,  but  I  wish  to  acknowledge  my  indebtedness  to  them,  the 
same  as  to  those  whose  names  are  mentioned. 

My  thanks  are  due  to  many  who  have  aided  me  in  preparing 
this  book,  especially  to  Dr.  J.  E.  Pottenger,  for  preparing  the 
chapter  on  laboratory  methods;  to  Dr.  R.  Walter  Mills,  for  his 
paper  on  the  relationship  of  physical  types  to  the  form  and  func- 
tion of  the  internal  viscera,  and  his  excellent  drawings  to  illus- 
trate the  same ;  to  Dr.  Albert  Soiland,  for  making  and  reading  the 
plates  of  the  patients  described  in  the  chapter  on  x-ray  diagnosis, 
and  for  furnishing  the  x-ray  pictures  for  the  cuts ;  to  Drury  Victor 
Haight,  for  preparing  most  of  the  illustrations  and  plates;  to  the 
Misses  Paine  and  Hardy,  for  preparing  most  of  the  temperature 
charts;  to  Mr.  Culver,  for  making  the  charts  illustrating  graphi- 
cally the  method  of  employing  tuberculin  according  to  the  extent 
and  degree  of  activity  of  the  disease ;  to  Mr.  Lacy,  for  photographs 
and  drawings;  to  M.  S.  Pottenger,  for  correcting  and  reading  the 
manuscript;  to  Miss  Henrickson  and  Mrs.  Sanford,  for  copying 
the  manuscript;  and,  last  but  not  least,  to  my  assistants  and  pa- 
tients who  helped  me  in  making  observations  and  collecting  data. 

I  desire  especially  to  thank  the  publishers  for  their  untiring  ef- 
forts to  meet  the  difficult  problems  put  up  to  them  in  the  mechan- 
ical part  of  the  work. 

Francis  M.  Pottenger. 


CONTENTS 


VOLUME  I. 

PATHOLOGICAL     ANATOMY,     PATHOLOGICAL     PHYSI- 
OLOGY, DIAGNOSIS,  AND  PROGNOSIS. 

CHAPTER  I. 
Pathological  Changes   in  Tuberculosis 26 

Tubercle — Collateral  Inflammation — Recognition  of  Tuberculous  In- 
flammations— Conglomerate  Tubercle — Tuberculous  Ulcer — Avenues 
of  Infection — The  Localization  of  Tuberculosis — Differences  in  Air- 
borne and  Blood-borne  Intrathoracic  Diseases — The  Effect  of  Cell 
Sensitization  Upon  the  Implantation  ,of  Bacilli — Lymphatic  Metas- 
tasis— Bronchogenous  Metastasis — Hematogenous  Metastasis — Forms 
of  Tuberculosis — Miliary  Tuberculosis — Fibroid  Tuberculosis — Case- 
ous Tuberculosis  —  Fibrocaseous  Tuberculosis  —  Non- tuberculous 
Changes  in  Other  Organs — Degeneration — Amyloid  Degeneration — 
Fatty  Degeneration — Cloudy  Swelling — General  Congestion — Changes 
in  Nerves — Changes  in  Muscles — Changes  in  the  Skin  and  Subcu- 
taneous Tissue — Changes  in  Blood  Vessels — Non-pulmonary  Tuber- 
culosis— Nasal,  Tonsillar,  and  Pharyngeal  Tuberculosis — Laryngeal 
Tuberculosis — Tuberculous  Pleurisy — Tuberculous  Pericarditis — Tu- 
berculous Peritonitis — Tuberculous  Enteritis — Tuberculosis  of  the 
Liver — Tuberculosis  of  the  Spleen — Tuberculosis  of  the  Glands. 

CHAPTER  II. 

The  Source  and  Routes  of  Infection  and  the  Primary  Focus    ...    57 

Source  of  Infection — -Bovine  Infection  Cannot  be  Differentiated 
from  Human  Infection  Either  by  Localization  or  Character  of  the 
Lesion — Incubation  Period  in  Tuberculosis — Infection  Through  the 
Respiratory  Tract — Comparison  of  Infection  in  Tuberculosis  and  Def- 
inite Air-borne  Disease — Droplet  Infection — Infection  Through  the 
Alimentary  Tract — Tonsils — Infection  Through  the  Digestive  Tract — 
Difficulty  of  Determining  Source  of  Infection — Other  Methods  of 
Infection. 

CHAPTER  III. 

Relationship  of  the  Primary  Focus  to  Clinical  Tuberculosis    ...    82 

Differentiation  Between  Primary  Focus  and  Primary  Metastasis — Tu- 
berculosis Primarily  a  Lymphatic  Disease — Metastatic  Tuberculosis — ■ 
Relationship  of  Primary  Metastasis  to  Clinical  Tuberculosis — Infec- 
tions from  Without  in  Later  Life. 


16  CONTENTS 

CHAPTER  IV. 

Tuberculosis  in  Childhood 93 

The  Natural  Defense  of  the  Little  Child — 'Infection  and  Immunity — 
The  Difference  in  the  Tuberculous  Process  at  Different  Age  Periods — 
What  Predisposes  a  Child  to  Infection — Frequency  of  Tuberculosis  in 
Children — Fate  of  Early  Lesions — The  Effect  of  Tuberculous  Infec- 
tion Upon  the  Child — The  Importance  of  Eecognizing  Latent  or  Par- 
tially Latent  Lesions  in  Early  Life — Tuberculosis  of  the  Mesenteric 
Glands — The  Diagnosis  of  Active  Glandular  Tuberculosis. 

CHAPTER  V. 

Factors  Which  Predispose  to  Tuberculosis.  Why  the  Apex  is  In- 
volved. A  Critical  Study  of  Freund's  Theory  of  the  Ossi- 
fication of  the  First  Costo-Sternal  Articulation  and  Short- 
ening of  the  First  Costal  Ring,  as  Predisposing  Factors  in 
Apical   Tuberculosis 117 

Disposition  and  Predisposition — Pulmonary  Focus — Metastatic  Tuber- 
culosis— Commonly  Recognized  Factors  Predisposing  to  Formation  of 
Pulmonary  Metastases — Localization  in  the  Child  and  Adult  Differs — 
Anatomical  Facts  Bearing  on  Pulmonary  Infection — Apical  Compres- 
sion Following  Anatomical  Growth  Slows  Blood  and  Lymph  Cur- 
Tent — Critical  Examination  of  Theories  of  Freund,  Schmorl  and 
Rothschild — Habitus  Phthisicus — The  Small  Heart. 

CHAPTER  VI. 

The  Nervous  System  in  Tuberculosis 150 

Psychoses — Psycho-Neuroses — Pathology  of  Psychoses  and  Psycho- 
neuroses — Tuberculosis  and  the  Peripheral  Nerves — Pathology  of  Neu- 
ritis in  the  Tuberculous. 

CHAPTER  VII. 

The  Nervous  System  (Continued)  :  The  Vegetative  Nervous  System 
in  its  Relationship  to  Diseases  of  the  Lungs  :  A  Discussion 
of  Principles,  Including  the  Antagonistic  Action  Which  is 
Manifested  Between  the  Greater  Vagus  and  Sympathetic 
Divisions    .      .     .     , 168 

Joint  Chemico-Physical,  Sensori-Motor  and  Psychical  Control — The 
Vegetative  Nervous  System — The  Inhibitory  Action  of  Visceral 
Nerves — Grouping  of  Structures  Supplied  by  the  Sympathetic  and 
Greater  Vagus  Systems — Symptoms  Due  to  Stimulation  of  Vegeta- 
tive Nerves  are  Variable — Segmentation  of  the  Body — Segmental 
Relationship  of  the  Lungs — Lungs  Embryologieally  Formed  From  In- 
testine— The  Relation  of  Symptoms  in  Tuberculosis  to  the  Greater 
Vagus  and  Sympathetic  Divisions  of  the  Vegetative  Nervous  System — 
Antagonistic  Action  of  Greater  Vagus  and  Sympathetic  Fibers  Shown 
in  Variability  of  Symptoms — Effect  of  Internal  Secretions  on  Symp- 
tomatology— Internal  Secretion  of  the  Thyroid — Internal  Secretion  of 
the  Ovary — Antagonistic  Action  of  Greater  Vagus  and  Sympathetic  as 
Shown  in  Symptoms  of  Pulmonary  Tuberculosis — Dilated  Pupil — 
Hectic  Flush — Heart — Intestinal  Tract — Influence  on  the  Salivary 
Flow — Tongue  Atrophy — Motor  and  Sensory  Disturbances  in  Pharyn- 
geal Structures — Coated  Tongue — Stomach — Intestines. 


CONTENTS  17 

CHAPTER  VIII. 

The  Nervous  System  (Continued)  :  The  Relationship  of  the  Sympa- 
thetic Nervous  System  to  Toxemia  and  the  Depressive  Emo- 
tional States  in   General 217 

CHAPTER  IX. 

The  Circulatory  System  in  Tuberculosis 230 

Nervous  Influences  Upon  the  Heart  in  Tuberculosis — Physiological 
Facts — Effect  of  Pathological  Reduction  in  Pulmonary  Areas — Blood 
Pressure  in  Tuberculosis — Small  Heart  and  Arteries — Hypertrophy  of 
Right  Ventricle — Thickening  of  Arteries  in  Tuberculosis — Tubercu- 
lous Lesions  of  the  Blood  Vessels — Difficulties  in  Examining  Heart 
in  Tuberculosis — Organic  Heart  Lesions  and  Tuberculosis — Heart 
Bruits — Degeneration  of  Heart  Muscle — Clinical  Evidence  of  Failing 
Heart — Treatment  of  Failing  Heart. 

CHAPTER  X. 

The  Digestive  System  in  Tuberculosis 251 

General  Observations  on  Nutrition — Nutrition  in  Tuberculosis — The 
Digestive  Tract  and  the  Vagus  and  Sympathetic  Nervous  Systems  in 
Tuberculosis — Appetite — Disturbance  on  the  Part  of  the  Stomach — 
Hypochlorhydria — Hyperchlorhydria — Dilatation  of  the  Stomach — 
Disturbance  on  the  Part  of  the  Intestines — Enterocolitis — Diet  Per- 
mitted in  Severe  Cases — Moderately  Severe  Cases — Mild  Cases — Foods 
Forbidden — Intestinal  Stasis — Constipation — Atonic  Constipation — 
Spastic  Constipation — Biliousness  (So-called) — Nervous  Influences  in 
Gastro-Intestinal  Disturbances- — Amyloid  Degeneration — Errors  in 
Diet. 

CHAPTER  XI. 

Compensatory  Changes  in  the  Thoracic  and  Abdominal  Cavities  Re- 
sulting From  Pulmonary  Tuberculosis 281 

Compensatory  Changes  Taking  Place  Within  the  Thoracic  Cavity — 
Shifting  of  Mediastinum — Displacement  of  the  Heart — Effect  of  Dis- 
placement of  the  Heart — Compensatory  Changes  in  Thoracic  Cage — 
Compensatory  Changes  Taking  Place  Between  the  Thoracic  and  Ab- 
dominal Cavities  in  Pulmonary  Tuberculosis — The  Inspiratory  Act — 
Inspiratory  Act  and  Circulation — Symptoms  Following  Deficient  In- 
spiratory Act — Particular  Alterations  in  Position  and  Function  of  the 
Diaphragm  in  Pulmonary  Tuberculosis — Effect  of  Arterial  Hypoten- 
sion and  General  Wasting  of  Tissues  upon  Body  Activities. 

CHAPTER  XII. 
Traumatic  Tuberculosis 312 

CHAPTER  XIII. 

Important  Anatomical  and  Physiological  Facts  to  be  Considered  in 
Making  Physical  Examination  op  the  Organs  Within  the 
Thorax 319 

Projection  of  Lung  on  Anterior  Surface  of  Chest — Normal  Border  of 
Lungs — Position  of  Diaphragm  at  Different  Age  Periods — Position  of 


18  CONTENTS 

Sulci  Which  Separate  Lobes — Projection  of  Peritracheal  and  Peri- 
Bronchial  Glands  on  Body  Surface — Muscles  Employed  in  Normal 
Eespiration — Influence  of  Diaphragm  in  Eespiration — Muscles  Em- 
ployed in  Forced  Eespiration — Segmental  Distribution  of  Nerves  to 
the  Somatic  Muscles — Importance  of  Muscles  and  Soft  Tissues  on 
Physical  Findings — Normal  Well-Formed  Thorax — Common  Occupa- 
tional Changes  in  the  Soft  Tissues  of  the  Thorax — The  Eelation  of 
Visceral  Form — Topography  and  Function  to  the  General  Physique, 
with  a  Classification  of  Types. 


CHAPTEE  XIV. 

The  Diagnosis  of  Early  Pulmonary  Tuberculosis:      History  and 

Clinical  Symptoms 357 

Clinical  Tuberculosis — Eelationship  of  Clinical  Diagnosis  to  Infec- 
tion— Clinical  Diagnosis — Family  History — Clinical  History — History 
of  Past  Illness — Slow  Eeeovery  from  Other  Diseases — Present  Ill- 
ness— Classification  or  Early  Symptoms — General  Characteristics  of 
Toxic  Group — Symptoms  Due  to  Tubercle  Toxins — Malaise,  Nervous 
Instability,  a  Feeling  of  Being  Eun  Down,  Lack  of  Endurance — 
Gastro-Intestinal  Symptoms — Night  Sweats — Eise  in  Temperature — 
Acceleration  of  the  Pulse — Symptoms  of  Eeflex  Origin — Hoarseness — 
Tickling  in  the  Larynx  and  Dry  Hacking  Cough — Disturbance  in 
Heart  Action — Loss  of  Weight — Chest  and  Shoulder  Pains — Flushing 
of  the  Face — Symptoms  Due  to  the  Tuberculous  Process  Itself — Fre- 
quent and  Protracted  Colds — 'Spitting  of  Blood — Pleurisy — Sputum — 
Temperature — Eelative  Value  of  the  Various  Groups  of  Symptoms. 

CHAPTEE  XV. 

The  Diagnosis  of  Early  Pulmonary  Tuberculosis:    Physical  Exam- 
ination of  the  Patient 394 

General  Considerations — Favorable  Conditions  for  Making  Examina- 
tion Important — Methodical  Examination  Necessary — Physician's 
Duty  in  Suspected  Cases — Etiological  Classification  of  the  Changes 
Found  on  Physical  Examination — Factors  Causing  Changes  on  In- 
spection, Palpation,  Percussion  and  Auscultation — Factors  Which  Af- 
fect Soft  Structures  Covering  the  Bony  Thorax — Cause  of  Eeflex 
Spasm  and  Degeneration  of  Soft  Tissues — Example  of  the  Effect  of 
Spasm  and  Degeneration — Inspection — Dilatation  of  the  Pupil — Lag- 
ging, Eegional  and  General— State  of  Muscles  and  Subcutaneous  Tis- 
sue—Occupational and  Pathological  Changes  in  Soft  Parts  Covering 
the  Apex— Change  in  Contour  of  Trapezius  Muscle— Mammary 
Gland — Palpation — What  Can  be  Determined  by  Palpation — Eegional 
Spasm  of  Muscles — Eegional  Atrophy  of  Skin,  Muscles  and  Sub- 
cutaneous Tissue — Determining  of  Pulmonary  Infiltrations  by  Pal- 
pation— Lagging — Tactile  Fremitus — Enlarged  Glands — Percussion — 
Light  or  Heavy  Percussion — Percussion  Changes  in  Early  Clinical 
Tuberculosis — Conditions  Within  the  Chest  Which  Alter  the  Per- 
cussion Note — Percussion  Gives  No  Evidence  of  Activity — Kroenig's 
Apical  Percussion — Auscultation — Stethoscope — Method  of  Breathing 
During  Auscultation— The  Effect  of  Muscles  on  the  Eespiratory 
Note — Eespiratory  Sounds  in  Early  Tuberculosis — Weakened  and  Im- 
peded Breathing— Why  Eespiratory  Sounds  Differ  in  Early  Tuber- 
culosis—Interpretation of  Auscultatory  Findings— Whispered  Voice. 


CONTENTS  19 

CHAPTER  XVI. 

The  Signs  and  Symptoms  of  Advanced  Pulmonary  Tuberculosis    .    .  435 

General  Considerations — Classification  of  Symptoms  of  Advanced 
Tuberculosis — Malaise,  Lack  of  Endurance,  and  Loss  of  Strength — 
Digestive  Disturbances — Loss  of  Weight — Circulatory  Disturbances — 
Night  Sweats — Fever — Hoarseness — Tickling  in  Larynx  and  Cough — 
Chest  Pains — Symptoms  on  the  Part  of  the  Nervous  System — Acid- 
osis— Dyspnoea — 'Hectic  Flush — Sputum — Pleurisy — Frequent  and  Pro- 
tracted Colds — Hemoptysis — Menstruation. 

CHAPTER  XVII. 

The  Physical  Examination  of  the  Patient  in  Advanced  Pulmonary 

Tuberculosis 464 

Inspection — Muscle  Spasm;  and,  Degeneration  of  Muscles,  Subcuta- 
neous Tissue  and  Skin — Changes  in  Contour  and  Movement  of  Chest 
Wall — Palpation — Palpation  of  Muscles  and  Subcutaneous  Tissue — 
Motility  of  Chest  Wall — Determination  of  Different  Degrees  of  Den- 
sity by  Palpation- — Percussion — Auscultation — Respiratory  Rhythm — 
Quality  of  Note — Rales — Adventitious  Sounds  Resembling  Intrapul- 
monary  Rales — Extensive  Infiltration  in  One  Lung — Fibrosis — Cav- 
ity— Compensatory  Emphysema — Dry  Pleurisy — Pleural  Effusion — 
Thickened  Pleura — Mediastinal  Thickening. 

CHAPTER  XVIII. 
Tuberculin  Tests  in  Diagnosis 502 

General  Considerations — The  Subcutaneous  Test — Temperature — The 
Cutaneous  Test  (von  Pirquet) — The  Percutaneous  Test  (Moro) — The 
Conjunctival  Test  (Wolff-Eisner) — The  Intradermal  Test. 

CHAPTER  XIX. 
The  X-Ray  as  an  Aid  to  the  Diagnosis  of  Pulmonary  Tuberculosis    .  516 

Relative  Value  of  Physical  and  X-Ray  Examinations — Interpreta- 
tion of  Plate — The  Normal  Hilus  and  Trunk  Shadows — Method  of 
Using  X-Ray  in  Pulmonary  Diagnosis — Cases  Illustrating  Compara- 
tive Results  of  Clinical  and  Stereoscopic  Examination. 

CHAPTER  XX. 
Laboratory  Methods 533 

Sputum — 'Collection  of  Specimens — Cytological  Examination — Fermen- 
tation and  Determination  of  Sediment  Volume — Albumen  Reaction — 
Studies  on  the  Distribution  of  Tubercle  Bacilli  in  Sputum  and  Other 
Conditions  of  Importance  in  Their  Demonstration — Technics  for  the 
Preparation  of  Sputum— Staining  of  Tubercle  Bacilli— Number  of 
Tubercle  Bacilli — Morphological  Classification — Urine — Collection  of 
Specimens — Diazo  Reaction — Urochromogen — Indiean  Determination — 
Blood — General  Differentiation — Arneth's  Classification  of  Neutro- 
phils— Neuclear  and  Protoplasmic  Changes  in  the  Neutrophile — 
Feces — Interpretation  of  Laboratory  Findings. 


20  CONTENTS 

CHAPTEE  XXI. 

The  Diagnosis  and  Differential  Diagnosis  of  Tuberculosis,  Particu- 
larly  Pulmonary   Tuberculosis 596 

The  Importance  of  Diagnosis  in  Hidden  Tuberculosis — Difficulties  of 
Diagnosis — The  Importance  of  the  Tuberculin  Tests  in  Diagnosis — 
Variability  of  Tuberculins — Importance  of  Clinical  History  in  Diag- 
nosis— What  Value  Has  Physical  Examination  in  Diagnosis — The  X- 
Eay  in  the  Early  Diagnosis  of  Tuberculosis — Differential  Diagnosis — 
General  Asthenic  Constitution — Neurasthenia — Malaria — Acute  or 
Subacute  Bronchitis — Intercostal  Neuralgia — Influenza — Chronic  Pur- 
ulent Bronchitis  and  Bronchiectasis — Chronic  Fibrosis — Pulmonary 
Infarct — Pneumonia — Pulmonary  Syphilis  —  Actinomycosis — Strepto- 
thricosis — Blastomycosis,  Aspergillosis,  and  Coccidioidal  Granuloma — 
Malignant  Tumors  of  the  Lung. 

CHAPTEE  XXII. 

Prognosis 624 

Introductory  Eemarks — Age — Constitution — Environment — Economic 
Status — Mental  State — <Earliness  of  Diagnosis  and  Treatment — The 
Character  of  the  Lesion  in  Pulmonary  Tuberculosis — Miliary  Tuber- 
culosis— Fibroid  Tuberculosis — Chronic  Ulcerative  Tuberculosis — 
Acute  Caseous  Tuberculosis — The  Tuberculin  Eeaction — Tuberculous 
Complications — Tuberculosis  of  the  Larynx — Tuberculosis  of  the  In- 
testines— Pleurisy — Pneumothorax — Tuberculous  Meningitis — Non-tu- 
berculous Complications — Nervous  System — The  Eespiratory  System — 
The  Digestive  System — The  Circulatory  System — Urine — The  Diazo 
and  Urochromogen  Eeactions — Blood  in  Tuberculosis — Bacilli — Prog- 
nosis from  the  Standpoint  of  the  Physician — Co-operation  of  the 
Patient — Character  of  Treatment — Sanatorium  Versus  Home  Treat- 
ment— Open  Air — Climate — Heliotherapy — Hydrotherapy — Food,  Eest 
and  Exercise — Psychotherapy — Tuberculin — Induced  Pneumothorax — 
.  Pharmacological  Eemedies — Pregnancy — Change  of  Occupation. 


ILLUSTRATIONS 


FIG.  PAGE 

1.  Schematic  illustration  of  a  tubercle 26 

2.  Illustrating  conversion  of  tubercle  into  scar  tissue 26 

3.  Illustrating  conversion  of  tubercle  into  necrotic  tissue 27 

4.  Schematic  illustration  of  the  manner  in  which  tuberculous  ulcerations 

or  cavities  are  formed 28 

5.  Illustrating    schematically    aneurismal    dilatation   of    a   vessel   in   a 

cavity 29 

6.  Illustrating  disproportion  between  lesion  in  the  lung   and  the   en- 

largement of  the  peribronchial  glands  in  a  child  in  whom  im- 
munity has  not  been  established  by  previous  infection     ...  32 

7.  Miliary  tuberculosis  of  the  lung 39 

8.  Fibro-caseous    tuberculosis 40 

9.  Sacculated  bronchiectasis 41 

10.  Caseous  tuberculosis 42 

11.  Tuberculosis  of  the  tongue 46 

12.  Schematic  illustration  of  infection  with  and  without  cellular  defense  83 

13.  Showing  the  course  of  the  lymphatics  from  the  tonsillar  region  into 

the  deep  cervical  glands 93 

14.  Showing  the  drainage  from  the  oropharynx  into  the  deep  cervical 

glands 94 

15.  Showing  the  peribronchial   and  peritracheal   glands 95 

16.  Illustrating  the  method  of  palpating  for  increased   density  in  the 

mediastinum 115 

17.  Illustrating  schematically  the  difference  in  the  elevation  of  the  an- 

terior portion  of  the  ribs  of  children  and  adults 126 

18.  Illustrating  the  relationship  between  the  anteroposterior  and  trans- 

verse diameters  of  the  chest  at  different  age  periods     ....     127 

19.  Illustrating  the  inclination  of  the  ribs  at  various  age  periods     .     .     129 

20.  Illustrating  the  relative  increased  anteroposterior  compression  of  the 

apex  which  takes  place  in  man  as  the  result  of  assuming  the 
erect  position,  as  compared  with  the  four-legged  animals     .     .     130 

21.  Illustrating  schematically  the  movements  of  the  various  portions  of 

the  lung 132 

22.  Illustrating  the  mediastinal  aspect  of  the  right  lung  which  shows  the 

degree  of  respiratory  movement  at  the  root 133 

23.  Illustrating  the  action  of  the  first  pair  of  ribs  and  manubrium  in 

increasing  the  area  of  the  lung  during  inspiration 134 

24.  Schematic  illustration  of  the  vegetative  nervous   system     ....     171 

25.  Schematic  illustration  of  the  course  of  the  fibers  in  the  sympathetic 

nervous  system 172 

26.  Diagram  of  the  human  embryo  showing  the  segmentation  of  the  body  178 

27.  Head's  zones,  anterior  surface  of  the  body 182 

28.  Head's  zones,  posterior  surface  of  the  body 183 

29.  Chart  showing  vagus  tonus,  as  indicated  by  pulse 200 

30.  Chart  showing  predominant  vagus  tonus,  as  indicated  by  pulse     .     .  202 

31.  Vagus  tonus  predominating,  as  indicated  by  pulse,  in  acute  caseous 

pneumonia 203 

32.  Vagus  tonus  predominating,  as  indicated  by  pulse,  in  acute  caseous 

pneumonia 204 


22  ILLUSTRATIONS 

PIG.  PAGE 

33.  Showing  the  manner  in  which  pulse  and  temperature  follow  each 

other  during  periods  of   toxemia 207 

34.  Sympathetic  tonus  predominating,  as  indicated  by  pulse     ....  208 

35.  Sympathetic  tonus  predominating,  as  indicated  by  pulse     ....  209 

36.  Sympathetic  tonus   predominating   prior   to   menstruation     ....  212 

37.  Showing  effect  of  fear  and  worry  in  increasing  pulse  rate  and  raising 

temperature 233 

38.  Terminal  dilatation  of  the  heart 246 

39.  Terminal  dilatation  of  the  heart 247 

40.  Showing  distortion  of  the  thoracic  viscera  in  advanced  destructive 

tuberculosis,  Case  544 286 

41.  Schematic  illustration  of  the  displacement  of  the  heart  to  the  left  289 

42.  Schematic  illustration  of  the  displacement  of  the  heart  to  the  right  290 

43.  Illustration  of  the  normal  thoracic  type  of  breathing 297 

44.  Illustration  of  the  abdominal  type  of  breathing 298 

45.  Illustration    of    the    combined    thoracic    and    abdominal    types    of 

breathing 299 

46.  Sagittal  section  of  the  body  showing  the  relationship  of   the   dia- 

phragm to  the  pericardium,  and  emphasizing  the  importance  of 

the  contraction  of  the  crus 300 

47.  The  movement  of  the  ribs  and  sternum  during  inspiration     ....  301 

48.  Schematic  representation  of  the  compensation  between  the  two  sides 

of  the  chest  and  between  the  thoracic  and  abdominal  cavities, 

Case    2414 310 

49.  Showing  the  relationship  of  the  anterior  surface  of  the  lung  to  the 

anterior   surface   of   the   chest 320 

50.  The  relationship  of  the  lungs  to  the  anterior  chest  wall 320 

51.  The  normal  borders  of  the  lungs  and  the  location  of  the  interlobular 

septi.      Anterior    view 322 

52.  The  normal  borders  of  the  lungs  and  the  location  of  the  interlobular 

septi.     Posterior  view 323 

53.  The  normal  borders  of  the  lungs  and  the  location  of  the  interlobular 

septi.    Lateral  view 324 

54.  Position  of  the  diaphragm  and  intrathoracic  and  abdominal  organs 

at  birth , 324 

55.  Position  of  the  diaphragm  and  intrathoracic  and  abdominal  organs 

in  adult,  36  years  of  age 324 

56.  Position  of  the  diaphragm  and  intrathoracic  and  abdominal  organs 

in  adult,  72  years  of  age 324 

57.  Location  of  the  sulcus  between  upper  and  lower  lobes  of  lungs     .     .  324 

58.  Position    of    the    bifurcation    of    the   trachea   projected    upon    the 

anterior   surface   of   the   chest 326 

59.  Position    of    the    bifurcation    of    the   trachea    projected    upon    the 

posterior  surface  of  the  chest 327 

60.  Schematic  illustration  of  the  influence  of  the  diaphragm  in  enlarging 

the  intrathoracic  space 328 

61.  Side  view  of  the  muscles  of  the  neck 330 

62.  The  pectoralis 330 

63.  Superficial  muscles  of  the  neck,  posterior  view 332 

64.  Second  layer  of  muscles  of  the  back 332 

65A.  Sagittal  section  through  the  body 334 

65B.  Sagittal  section  through  the  body 334 

65C.  Sagittal  section  through  the  body 334 

66.  Hypersthenic   habitus 342 

67.  Asthenic  habitus 343 

68.  The    sthenic   habitus 346 

69.  The  hyposthenic  habitus 347 


ILLUSTRATIONS  23 

PIG.  PAGE 

70.  The  hypersthenic  habitus 348 

71.  The   sthenic   to   hypersthenic   habitus 349 

72.  The    sthenic    to    hyposthenic    habitus 350 

73.  The  hyposthenic  to  sthenic  habitus 351 

74.  The   hyposthenic  to   asthenic  habitus 352 

75.  The  asthenic  to  hyposthenic  habitus 353 

76.  Chart  illustrating  the  importance  of  early  morning  temperature     .     .  374 

77.  Chart  illustrating  the  importance  of  early  morning  temperature     .     .  375 

78.  Showing  the  importance  of  temperature  record  over  many  days  to 

determine  condition  ox  patient 377 

79.  Showing  the  influence  of  nervous  condition  in  raising  temperature 

curve   and  increasing   pulse   rate 379 

80.  Influence  of  complications  on  temperature  curve 382 

81.  Schematic  illustration  of  vagus  reflex  through  the  superior  laryngeal 

nerve      .          386 

82.  Schematic  illustration  of  vagus  seflex  through  the  inferior  laryngeal 

nerve 386 

83.  Method  of  detecting  lagging  at  the  apices 404 

84.  Method  of  detecting  lagging  at  the  base 404 

85.  Showing  the  change  in  the  contour  of  the  trapezius  muscle     .     .     .  408 

86.  Method  of  palpating  to   determine  condition  of  muscles  and  other 

soft  tissues 411 

87.  The  acoustic  sphere  of  action  of  the  blow  in  deep  percussion     .     .  418 

88.  Illustrating  a  common  error  in  percussing  the  apices 419 

89.  Showing  schematically  important  muscles  which  affect  percussion  of 

apices 419 

90.  Schematic  illustration  of  the  degenerative  effects  upon  soft  tissues 

produced  reflexly  by  an  old  chronic  inflammation  in  the  apex 

of  the  lung 422 

91.  Temperature    chart   of   chronic    fibro-ulcerative   tuberculosis   during 

quiescence 446 

92.  Temperature   chart    of    chronic   flbro-ulcerative    tuberculosis    during 

slight  activity 448 

93.  Temperature    chart    showing    marked    activity    in    chronic    caseous 

tuberculosis 449 

94.  Phthisical  chest,  anterior,  posterior  and  lateral  views 465 

95.  Illustrating  marked  regional  degeneration  of  muscles  and  soft  tis- 

sues as  a  result  of  chronic  tuberculosis 466 

96.  Showing  regional  degeneration  of  soft  tissues  due  to  chronic  tuber- 

culosis   468 

97.  Showing  regional  degeneration  of  soft  tissues  due  to  chronic  tuber- 

culosis      468 

98.  Temperature  curves  due  to  tuberculin  reactions 512 

99.  Peribronchial  thickening  in  a  child  6^  years  of  age 528 

100.  Device  for  classifying  tubercle  bacilli  according  to  length     .     .     .  566 

101.  Bulb  and  pipette  for  convenience  in  making  quantitative  indican 

determinations 573 

102.  Institutional   indican    curve   determined    from    the    average    of    all 

indican  findings  for  the  month 588 

103.  Chart  showing  correlation  of  sputum  findings  and  their  relation  to 

temperature    curve 593 

104.  Chart  showing  correlation  of  sputum  findings  and  their  relation  to 

temperature    curve 594 

105.  Metastatic  sarcoma  of  the  lung 623 


24  ILLUSTRATIONS 

PLATES 

PLATE  PAGE 

I.  The  reflex  paths  in  the  bulbar  portion  of  cord 170 

II.  Showing  the  connection  between  the  sympathetic  and  spinal  nerves 

in   the    spinal    cord 173 

III.  Schematic  illustration  of  the  reflex  paths  from  the  inflamed  lung  to 

the  chest  and  neck  muscles,  anteriorly 400 

IV.  Schematic  illustration  of  the  reflex  paths  of  the  inflamed  lung  to 

the  chest  and  neck  muscles,  posteriorly 400 

V.  Schematic  illustration  of  the  motor  disturbances  of  the  central  ten- 
don of  the  diaphragm  resulting  from  inflammation  of  the  lung    403 
VI.  Tuberculin  reactions 515 


CLINICAL  TUBERCULOSIS 


CHAPTER  I. 
PATHOLOGICAL  CHANGES  IN  TUBERCULOSIS. 

The  changes  which  take  place  in  the  tissues  as  a  result  of  tuber- 
culous infection  are  many,  and  vary  according  to  the  location  and 
severity  of  the  infection.  Aside  from  the  formation  of  the  tuber- 
cle and  the  evolutionary  changes  through  which  it  passes,  there 
are  changes  in  adjoining  tissues  which  are  due  to  the  toxins  or 
different  bacillary  substances  which  diffuse  into  them.  There  are 
also  changes  of  a  non-tuberculous  nature  such  as  the  various  de- 
generations, the  interference  with  circulation  resulting  in  con- 
gestion, the  pathological  changes  due  to  reflex  action,  changes  in 
the  nerves,  in  the  blood  vessels,  and  in  the  blood  itself.  In  fact, 
no  tissue  of  the  body  escapes  unchanged  during  a  tuberculous 
process  of  severity  and  long  standing. 

Tubercle. — When  tubercle  bacilli  gain  entrance  into  the  tis- 
sues they  at  once  set  up  an  irritation  which  causes  an  inflamma- 
tory hyperemia.  There  is  a  gathering  of  leucocytes,  particularly 
lymphocytes,  and  the  fixed  cells  in  which  the  bacilli  are  found 
respond  to  the  irritation  and  proliferate.  This  reaction  results 
in  the  formation  of  the  tubercle.  Within  the  tubercle  lie  the  tu- 
bercle bacilli.  The  periphery  of  the  tubercle  consists  of  a  ring 
of  round  cells,  particularly  lymphocytes.  Within  this  lies  another 
ring  of  cells,  larger  than  the  leucocytes,  containing  one  nucleus 
the  so-called  epithelioid  cells  from  their  resemblance  to  the 
epithelial  cell.  These  cells  are  probably,  although  not  definitely 
proved,  derived  from  the  fixed  tissue  cells,  in  which  the  bacilli 
are  found.  In  the  center  of  the  tubercle  may  be  found  giant  cells. 
These  were  formerly  thought  to  be  essential  to  the  tubercle  and 
characteristic  of  tuberculosis,  but  are  now  known  to  be  sometimes 
wanting  and  sometimes  found  in  other  conditions.  The  giant 
cells  when  present  form  the  center  of  the  tubercle.  They  vary 
in  size  and  shape  and  contain  many  nuclei.    They  are  probably 


26  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

an  expression  of  necrosis  and  disappear  as  the  necrotic  process 
extends,  the  new  ones  taking  their  place  peripherally. 

The  growth  of  the  tubercle  is  quite  rapid.  In  two  weeks  from, 
the  time  infection  occurs,  it  is  large  enough  to  be  detected 
microscopically.    Fig.  1  is  a  schematic  illustration  of  a  tubercle. 

When  necrosis  occurs  and  extends  it  does  so  by  gradually  in- 
volving the  peripheral  cells.  If  the  infecting  microorganisms 
are  of  low  virulence  or  if  the  biochemical  properties  of  the  tis- 
sues are  resistant,  the  disease  takes  upon  itself  a  chronic  course, 
and  the  tissues  surrounding  the  tubercle  form  new  connective 
tissue,  which  tends  to  wall  in  or  to  separate  the  focus  from 
the  adjoining  structures.  If  the  tubercle  is  small  it  may  be 
changed  into  connective  tissue  and  leave  no  visible  marks  of 
its  existence.  If  larger  it  leaves  connective  tissue  in  its  place. 
Fig.  2  illustrates  the  conversion  of  tubercle  into  fibrous  tissue. 

At  the  same  time  that  the  leucocytes  are  gathering  and  the 
epithelioid  cells  are  forming  in  order  to  surround  the  bacilli, 
and  guard  the  organism  from  their  further  attacks,  the  bacilli 
are  multiplying  and  preparing  to  wage  an  offensive  campaign. 
Activity  in  a  tuberculous  process  means  that  the  bacilli  are 
multiplying.  In  their  growth  and  multiplication  they  produce 
toxins  which  cause  necrosis  of  the  tubercle  and  by  diffusing 
into  adjacent  tissues  set  up  irritation  which  results  in  an  exuda- 
tion and  impairment  of  the  local  cells.  Fig.  3  illustrates  a  tu- 
bercle with  necrotic  center. 

Collateral  Inflammation. — Aside  from  the  pathological  changes 
which  are  caused  directly  by  the  bacillary  process  there  is  an 
inflammation  of  greater  or  lesser  extent  and  severity  affecting 
the  tissues  adjacent  to  the  tubercles.  This  collateral  inflamma- 
tion depends  upon  the  virulence  and  number  of  bacilli  on  the 
one  hand  and  the  receptivity  of  the  tissues  on  the  other.  It 
may  be  a  productive  inflammation  or  a  degenerative  process. 
The  exudation  may  be  serous,  fibrinous,  cellular,  sanguinous,  or 
purulent.  It  may  undergo  the  same  changes  as  the  tubercle 
itself,  producing  new  connective  tissue,  or  softening.  Former- 
ly it  was  thought  that  these  changes  were  due  to  other  bacteria, 
so-called  mixed  infections;  but  now  it  is  known  that  all  these 
changes  can  be  produced  without  the  help  of  any  other  organ- 
ism than  the  tubercle  bacillus. 


"ISP* 


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»'-.'•*,.  tit    ;i   •*    < ;  ^hr  )\))(V\ 


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Fig-    1. — Schematic    illustration    of   a   tubercle.      Center,    necrotic   giant   cell;    second   layer, 
epithelioid   cells;    outer   layer,   lymphocytes.      (Adami.) 


Fig.  2. — Illustrating  conversion  of  tubercle  into  scar  tissue.     Tubercle  undergoing  fibrosis; 
center  partially  fibrous.      (Fowler  and   Godley.) 


b  — m 


Fig    3 Illustrating   conversion    of   tubercle   into   necrotic    tissue.      Tubercle   undergoing 

caseation.  A,  caseous  central  area;  B,  cellular  peripheral  area;  C-C ,  giant  cells;  D  small- 
celled  infiltration  of  surrounding  alveolar  walls  and  spaces;  E,  pigment.  (Fowler  and 
Godley.) 


1  THE   TUBERCLE  27 

The  collateral  inflammation  is  due  to  substances  which, 
passing  out  from  the  tubercle,  diffuse  into  the  tissues.  These 
may  be  specific  toxins,  produced  during  the  growth  of  the  bacil- 
li, or  substances  of  a  fatty  or  albuminous  nature  which  are  de- 
rived from  the  destruction  of  the  body  of  the  bacillus.  A  large 
factor  in  the  production  of  the  inflammation  is  the  presence  of 
proteolytic  enzymes.  The  inflammation  is  most  severe  near  the 
tubercle  and  less  so  further  away. 

Bacilli  often  pass  from  within  the  tubercles  out  into  the  tis- 
sues affected  by  collateral  inflammation,  and  set  up  new  foci 
of  infection.  These  metastatic  foci  are  more  serious  than  the 
collateral  inflammation  alone.  The  tissues  which  are  affected 
by  the  collateral  inflammation  are  especially  prone  to  infec- 
tion because  the  cells  are  injured  by  the  exudative  process  and 
there  is  a  stagnation  of  blood  and  lymph  which  prevents  the 
free  access  of  antibodies;  and  further  lodgment  of  bacilli  in 
the  tissues  is  favored  by  the  lessened  motion  of  the  part. 

Recognition  of  Tuberculous  Inflammations. — Tuberculosis 
shows  every  form  of  inflammatory  change;  and  while  there  are 
certain  changes  which  are  most  often  found  in  tuberculous  tis- 
sue, yet  there  are  none  that  are  absolutely  characteristic.  Ex- 
udates in  which  lymphocytes  predominate  are  considered  to  be 
of  tuberculous  nature,  while  those  in  which  polynuclears  pre- 
dominate are  considered  non-tuberculous.  This  will  not  always 
hold  true.  Polynuclear  leucocytes  sometimes  predominate  in 
the  cerebrospinal  fluid  in  tuberculous  meningitis  in  the  early 
stage  of  the  disease;  and  lymphocytes  may  be  found  in  large 
numbers  in  any  chronic  non-purulent  exudate.  Necrosis  and 
cheesy  degeneration  are  found  in  other  inflammations  as  well  as 
tuberculosis.  Even  the  tubercle,  as  previously  mentioned,  with 
its  giant  cells  may  be  found  in  other  inflammations. 

Conglomerate  Tubercle. — Large  foci  are  often  formed  by  a 
number  of  tubercles  fusing  together.  Such  conglomerate  tuber- 
cles, as  they  are  called,  may  be  only  as  large  as  a  small  marble, 
or  they  may  be  as  large  as  one's  fist. 

Tuberculous  Ulcer. — One  of  the  common  results  of  the  tuber- 
culous inflammation  is  the  tuberculous  ulcer.  This  is  a  result 
of  the  degenerative  changes  in  the  tubercle;  or,  if  large,  in  the 


28  PATHOLOGICAL   CHANGES   IN   TUBERCULOSIS 

conglomerate  tubercle.  As  long  as  tubercle  bacilli  are  capable 
of  multiplying  they  give  off  toxic  substances;  and  both  during 
growth  and  after  destruction  yield  substances  belonging  to  the 
fatty  and  protein  groups,  which  produce  necrosis  of  the  cells 
with  which  they  come  in  contact.  This  softening  of  the  tuber- 
culous mass  is  usually  accompanied  by  an  inflammatory  process 
and  a  rupture  of  the  walls  confining  it.  If  it  is  somewhere  on 
the  surface,  such  as  in  the  larynx,  or  pharynx,  a  superficial  ul- 
cer remains.  If  it  is  deep  in  the  tissues,  as  in  the  lung,  bone,  or 
kidney,  a  rupture  is  followed  by  a  loss  of  tissue,  a  cavity  re- 
maining. 

All  tuberculous  ulcers  and  cavities  are  formed  in  the  same  way, 
first  by  a  deposit  of  bacilli ;  second,  a  softening  of  a  mass  of  cells 
with  a  separation  of  the  tissues,  then  a  rupture,  usually  near  the 
center.    As  a  result  it  can  be  seen  that  the  edges  of  a  tuber- 


A  B  C 

Fig.  4. — Schematic  illustration  of  the  manner  in  which  tuberculous  ulcerations  or  cavities 
are  formed.  A,  deposit  of  bacilli;  B,  necrosis  of  the  mass;  C,  the  rupture  with  expulsion 
of  the  contents. 

culous  ulcer  are  undermined.  This  is  illustrated  schematically 
in  Fig.  4,  in  which  A  represents  implantation  of  bacilli  and  indu- 
ration of  tissue ;  B,  softening  of  center ;  C,  rupture  and  expulsion 
of  abscess  contents  with  edges  of  surrounding  tissue  projecting 
beyond  the  abscess  walls. 

A  tuberculous  cavity  may  be  one  single  abscess  cavity  with 
regularly  formed  walls,  or  it  may  be  irregular,  the  result  of 
many  adjoining  abscesses.  The  walls  may  be  smooth  and  regu- 
lar, or  irregular.  They  may  always  secrete  or  they  may  even- 
tually dry  out.  They  may  always  remain  as  open  cavities  or 
they  may,  especially  when  small,  be  compressed  as  contraction 
occurs,  and  be  either  partially  or  wholly  closed.  The  walls  of 
cavities  when  chronic,  may  be  made  up  of  fibrous  tissue  one  or 
more  centimeters  in  thickness. 

Cavities  are  often  a  source  of  bleeding.  Sometimes  the  blood 
is  scant,  and  is  thoroughly  mixed  with  pus  from  the  cavity,  giv- 


CAVITIES  AND   HEMORRHAGE 


29 


ing  a  pinkish  appearance.  This  is,  as  a  rule,  from  delicate  new 
blood  vessels.  The  most  serious  hemorrhages,  however,  often 
come  from  larger  vessels  in  cavities.  Where  cavities  form,  the 
vessels,  as  a  rule,  are  closed  off  by  inflammatory  changes  in  their 
walls,  but  now  and  then  either  the  vessel  is  too  large  or  the  de- 
structive process  in  the  tissues  comes  too  rapidly  and  the  con- 
tents are  evacuated  while  the  vessel  still  remains  patulous.  The 
supporting  tissue  being  taken  away  from  the  walls  of  the  ves- 


Fig.  5. — Illustrating  schematically  aneurismal  dilatation  of  a  vessel  in  a  cavity,  rupture  of 
which  often  produces  hemorrhage. 

sel,  it  dilates,  forms  an  aneurism,  becomes  thinner  and  thinner, 
and  eventually  ruptures.  In  this  manner  many  fatal  hemor- 
rhages occur.  This  is  illustrated  in  a  schematic  way  by  Fig.  5. 
Avenues  of  Infection. — There  has  been  much  discussion  dur- 
ing recent  years  as  to  the  modes  of  entry  of  the  tubercle  bacil- 
lus into  the  human  body.  Formerly  it  was  taken  for  granted 
that  it  must  be  through  the  air  passages  because  the  lungs  were 
usually  involved.  Later,  entrance  through  the  alimentary  tract 
was  proved,  and  this  assumed  a  prominence  which,  for  a  time, 


30  PATHOLOGICAL    CHANGES  IN   TUBERCULOSIS 

completely  overshadowed  the  route  of  the  air  passages.  Animal 
experiments  have  been  performed  that  show"  that  both  routes 
are  capable  of  carrying  the  bacilli  to  a  safe  lodgment  in  the 
tissues.  They  also  enter  through  the  skin,  but  this  route  is  of 
comparatively  little  importance. 

Bacilli  do  not  require  injured  mucous  membranes  to  facili- 
tate their  passage,  but  penetrate  through  the  intact  surfaces. 
Bacilli  pass  through  the  intestinal  wall  and  may  be  carried  to 
the  liver,  or  lymphatic  glands ;  or,  through  the  thoracic  duct  and 
pass  directly  into  the  blood  stream.  Bacilli  injected  into  the 
rectum  have  been  found  within  a  few  days  in  the  mediastinal 
glands  and  lungs.  Bacilli  seem  to  find  their  way  to  the  peri- 
bronchial glands  no  matter  how  they  enter  the  body.  Until 
this  point  was  proved  it  was  thought  that  infection  must  be 
nearly  all  aerogenous  because  of  the  frequent  involvement  of 
the  lungs  and  bronchial  glands. 

In  1912  Ghon1  published  the  results  of  a  painstaking  post- 
mortem examination  of  chests  of  children  having  enlarged  peri- 
bronchial glands  and  showed  in  every  case  where  he  found 
certain  peribronchial  glands  infected  that,  by  examining  that 
portion  of  the  lungs,  whose  lymph  drained  into  these  glands, 
he  could  demonstrate  a  tuberculous  nodule.  This  work  seems  to 
substantiate  the  aerogenous  theory;  but  when  we  recall  that 
bacilli  might  be  taken  through  the  walls  of  the  alimentary  canal 
and  be  carried  through  the  thoracic  duct  and  poured  into  the 
blood  which  passes  through  the  lung  before  passing  on  to  the 
general  circulation,  we  can  see  that  even  alimentary  infection 
might  produce  foci  in  the  lungs  without  primary  involvement 
of  the  lymphatic  glands. 

The  route  of  entry  is  of  practical  importance  in  the  solution 
of  the  question  of  the  relative  danger  of  bovine  and  human  in- 
fection. The  chief  source  of  infection  from  cattle  is  milk;  and 
the  chief  avenue  of  infection  is  through  the  alimentary  tract. 
On  the  other  hand,  bacilli  of  human  origin  may  be  found  in  the 
air  we  breathe,  especially  in  closed  rooms  occupied  by  open 
cases  of  tuberculosis  living  under  unfavorable  hygienic  condi- 
tions ;  in  food  we  eat ;  or  in  droplets  of  sputum  thrown  from  the 
mouth  of  the  coughing  patient  (Fliigge).    So,  human  bacilli  may 


xDer  Primare  Lungenherd  bei  der  Tuberkulose  der  Kinder,  Wien,   1912. 


LOCALIZATION   OF   TUBERCULOSIS  31 

be  taken  into  the  body  either  through  the  air  passages  or  the 
alimentary  tract.  No  matter  in  which  way  they  enter,  the  process 
is  the  same. 

While  it  is  generally  believed  that  nearly  all  cases  of  pulmon- 
ary tuberculosis  in  the  human  being  are  due  to  human  tubercle 
bacilli,  and  that  the  extrapulmonary  lesions  are  more  apt  to 
be  due  to  bovine  bacilli;  this  question  is  far  from  being  proved, 
and  cannot  be  decided  on  the  basis  of  the  routes  of  infection. 
Some  have  thought  that  the  adaptability  of  the  tissues  to  the 
particular  strain  might  be  a  factor  in  localization,  while  the 
bacilli  of  both  varieties  gain  entrance  through  the  same  avenues. 
Both  types  have  equal  advantage  in  gaining  access  to  the  lym- 
phatic system  and  probably  follow  much  the  same  laws  in  their 
spread.  Neither  can  it  be  determined  by  the  severity  of  the 
process;  for,  as  a  general  rule,  the  method  of  producing  metas- 
tatic infection,  has  much  to  do  with  the  virulence  of  the  process. 
Processes  which  result  from  blood  metastases,  such  as  the  early 
lesions  in  the  lung,  those  in  bones,  joints  and  the  kidneys  are  mild 
infections,  while  those  which  spread  through  the  lymph  chan- 
nels, such  as  the  secondary  metastases  in  tissues  adjacent  to 
other  foci,  and  those  which  spread  through  the  bronchi  are  apt 
to  be  serious  infections.  For  a  more  complete  discussion  see 
page  57. 

The  Localization  of  Tuberculosis. — No  matter  whether  the 
bacilli  gain  entrance  through  the  air  passages  or  the  gastro- 
intestinal tract  their  localization  and  further  spreading  in  the 
body  seems  to  take  much  the  same  course.  Whether  the  bacilli 
gain  entrance  through  the  one  tract  or  the  other,  they  usually, 
eventually,  in  some  manner,  make  their  way  to  the  lymphatic 
glands  and  very  frequently  to  the  peribronchial  and  peritracheal 
glands.  The  mesenteric  glands  may  be  infected  when  bacilli 
enter  through  the  gastrointestinal  tract,  the  same  as  the  cervical 
when  the  tonsil  is  the  point  of  entry;  but,  on  the  other  hand,  it 
is  not  necessary  that  such  should  be  the  case,  for  bacilli  may  be 
carried  from  the  tonsils,  intestinal  walls  or  other  mucous  sur- 
faces to  the  lungs  and  mediastinal  glands,  leaving  these  regional 
glands  in  a  healthy  condition.  The  passage  of  bacilli  through 
groups  of  glands  is  particularly  apt  to  occur  in  childhood  be- 
cause of  the  peculiar  characteristics  of  the  glandular  structure 


32  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

in  early  life.  Bartel2  shows  that  the  canals  in  the  lymphatic 
gland  of  the  child  are  wide,  while  those  of  the  adult  are  narrow, 
thus  permitting  bacilli  to  pass  on  in  the  former,  while  they  are 
detained  in  the  latter.  In  the  former  bacilli  may  pass  on  through 
several  glands  before  finding  lodgment.  Lack  of  specific  cellu- 
lar defense  must  also  be  a  factor  in  inoculations  in  early  years. 

Even  if  the  primary  extraglandular  focus  should  be  some- 
where in  the  lungs,  as  has  been  shown  by  Ghon,  the  particular 
bronchial  glands  which  drain  the  area  also  become  infected,  en- 
large and  remain  a  nidus  whence  further  metastases  may  occur. 
The  primary  focus  is,  as  a  rule,  small.  The  glandular  focus,  on 
the  other  hand,  even  though  secondary,  is  apt  to  be  large  and 
out  of  all  proportion  to  the  primary  lesion.  This  is  illustrated 
in  Fig.  6,  from  Ghon's  monograph.  See  further  discussion  in 
Chapter  II. 

From  the  fact  that  the  glands  bear  such  a  prominent  part  in 
early  infections,  tuberculosis  must  be  looked  upon  as  being 
primarily  a  disease  of  the  lymphatic  system  which  produces 
secondary  or  metastatic  infections  in  almost  any  organ  of  the 
body,  but  which  shows  a  marked  predilection  for  the  lungs. 
It  might  be  suggested  that  one  reason  why  the  lungs  are  so 
often  the  seat  of  involvement  in  metastatic  tuberculosis  is  be- 
cause the  bacilli  pass  from  the  infected  lymphatic  glands  into 
the  blood  vessels  and  are  carried  through  the  lesser  circulatory 
system  to  the  lungs  before  circulating  in  other  parts  of  the 
body.  But  this  theory  leaves  some  phenomena  still  unexplained, 
especially  since  we  know  the  bacilli  are  often  found  in  the  sys- 
temic circulation  of  patients  suffering  from  tuberculosis  (Rosen- 
berg), particularly  advanced  tuberculosis.  We  know  no  reason 
why  we  should  not  assume  that  the  pulmonary  tissue  is  particu- 
larly favorable  to  the  growth  of  the  tubercle  bacillus  the  same 
as  the  tonsil  is  favorable  to  the  diphtheria  bacillus. 

Eosenow  has  shown  that  streptococci  cultivated  from  the  thy- 
roid localize  preferably  in  the  thyroid  in  experimental  infec- 
tion; those  grown  in  the  tonsil,  in  the  tonsil;  and  the  same  for 
bacteria  from  other  tissues.  It  is  quite  reasonable  to  suppose 
that  the  same  law  operates  in  the  localization  of  the  tubercle 


2Der  normale  und  abnormale  Bau  des  Lymphatischen   Systems  und  siene   Beziehungen 
zur  Tuberkulose;  Festschrift  zur  VI  Internationale!!  Tuberkulosen  Konferenz,  Wien,  1907. 


Fig.  6. — Illustrating  disproportion  between  lesion  in  the  lung  and  the  enlargement  of 
the  peribronchial  glands  in  a  child  in  whom  immunity  has  not  been  established  by  previous 
infection.  Primary  caseous  focus  in  the  left  upper  lobe,  with  miliary  tubercles  in  the 
surrounding  area.  Caseation  of  the  bronchopulmonary  lymphatic  glands  adjoining  the  left 
upper  lobe,  alongside  of  the  partially  visible  dissected  bronchus.  Caseation  of  the  upper 
tracheobronchial  lymphatic  glands  on  the  left,  and  adhesion  of  these  lymphatic  glands  with 
the  medial  surface  of  the  left  upper  lobe.  Acute  miliary  tubercles  in  the  lower  tracheo- 
bronchial lymphatic  glands.  Scattered  acute  miliary  tubercles  in  both  lungs.  The  upper 
tracheobronchial  and  bronchopulmonary  lymphatic  glands  on  the  right  are  unaltered.  The 
preparation  was  preserved  in  accordance  with  Kaiserling's  method,  and  is  taken  from  a 
four-year-old  boy.     Reduced  photograph  of  the  preparation.     Posterior  view.     (Ghon.) 


AIR-BORNE  AND   BLOOD-BORNE   INTRATHORACIC   DISEASES  06 

bacillus.  It  is  in  full  harmony  with  our  ideas  that  bacilli  grown 
on  a  given  medium  assume  peculiar  characteristics  and  become 
more  and  more  partial  to  that  medium. 

We  must  still  account  for  the  fact  that  the  apex  is  most  of- 
ten the  seat  of  infection.  This  question  is  discussed  in  Chapter 
V,  and  needs  no  further  discussion  at  this  time. 

Differences  in  Air-borne  and  Blood-borne  Intrathoracic  Dis- 
eases.— Bearing  upon  the  question  of  the  route  of  infection  and 
the  special  predisposition  of  the  apex  to  infection  in  tubercu- 
losis, important  information  can  be  gained  by  studying  other 
infections  of  the  lower  respiratory  tract.  The  special  bacteria 
which  produce  the  various  pneumonias  and  infections  of  the 
bronchial  tract  are  air-borne  and  often  found  in  a  saprophytic 
state  in  the  air  passages,  particularly  those  of  the  upper  respira- 
tory tract.  These  diseases  may  be  localized  in  any  portion  of 
the  lungs,  but  are  particularly  prone  to  infect  those  portions  of 
the  lung  which  receive  the  air  currents  most  directly,  and  in 
which  respiratory  movement  is  greatest ;  consequently  the  pneu- 
monias (lobar)  most  often  affect  the  lower  lobes;  and,  where 
other  lobes  are  also  involved,  the  disease  usually  makes  its  first 
appearance  in  the  lower  lobe.  Bronchitis  and  bronchial  pneu- 
monia may  affect  any  portion  of  the  lung  or  lungs ;  but  in  bron- 
chitis, as  a  rule,  the  infection  begins  in  the  trachea  and  large 
bronchi  where  the  parts  are  most  exposed  to  the  air  currents 
and  extends  progressively  toward  the  fine  ramifications  of  the 
air  passages.  If  the  smaller  tubes  and  air  cells  become  involved, 
causing  a  bronchial  pneumonia,  it  usually  shows  itself  first  at 
the  bases,  or,  at  least,  over  the  lower  portions  of  the  lungs. 
Thus  the  common,  definitely  accepted  air-borne  diseases  of  the 
lungs  affect  the  larger  bronchi  and  the  lower  lobes,  where  the 
entrance  of  the  air  is  most  direct  and  the  movements  great- 
est; and  we  would  expect  tuberculosis,  if  it  were  an  air-borne 
disease,  to  have  the  same  localization.  On  the  contrary,  disre- 
garding lesions  which  spread  contiguously  from  the  hilus,  the 
pulmonary  involvement  in  tuberculosis,  as  we  find  it  clinically 
and  pathologically,  usually  affects  first  the  apices  of  the  lungs 
and  then  spreads  downward  involving  contiguous  or  nearby 
tissue.  This  indicates  a  distinct  difference  in  the  mode  of  in- 
fection for  bronchitis  and  pneumonia  on  the  one  hand  and  tu- 


34  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

berculosis  on  the  other;  and  since  we  know  that  bacilli  are  car- 
ried to  the  lung,  both  by  the  blood  and  lymph  streams,  also  along 
the  paths  of  the  bronchi  in  secondary  metastases;  and,  since  we 
also  know  that  a  slowing  of  the  blood  and  lymph  current  takes 
place  at  the  apices,  favoring  the  deposit  of  bacilli  in  both  blood 
and  lymph  channels,  we  are  justified  in  suspecting  the  tubercle 
bacillus  to  follow  one  or  both  of  these  modes  of  gaining  access 
to  the  pulmonary  parenchyma.  This  indicates  that  pulmonary 
tuberculosis  is  metastatic  tuberculosis,  secondary  to  other  foci. 
Since  there  is  a  wide  gap  between  the  primary  focus  in  the 
gland  (usually  in  the  tracheal  and  peribronchial  group)  and  the 
apex  of  the  lung  where  the  first  pulmonary  metastatic  focus  oc- 
curs, we  must  assume  that  it  is  far  more  probable  that  the  metas- 
tasis is  a  result  of  infection  in  the  direction  of  the  natural  cur- 
rents of  the  blood  than  that  it  should  take  place  against  the 
current  of  lymph  which  flows  from  the  apex  toward  the  hilus. 

The  Effect  of  Cell  Sensitization  Upon  the  Implantation  of 
Bacilli. — We  cannot  consider  the  train  of  events  which  takes 
place  in  the  spreading  of  tuberculosis  from  the  lymphatic  sys- 
tem to  other  tissues,  without  at  the  same  time  considering  the 
degree  of  immunity  present  in  the  patient's  body  and  the  im- 
munity reactions  which  occur  between  the  tissues  and  the  bacilli 
which  have  made  their  escape  from  the  previous  foci. 

We  are  probably  justified  in  assuming,  if  we  interpret  experi- 
mental results  correctly,  that  every  patient  who  has  an  infec- 
tion of  any  portion  of  the  body  has  struggled  with  the  bacillus ; 
and  while  it  may  be  that  he  has  not  been  fully  able  to  overcome 
it,  yet  he  has  at  least  developed  a  more  or  less  marked  immu- 
nity against  it.  And  we  must  also  believe  that  a  more  or  less 
continuous  inoculation,  with  its  resultant  immunization,  goes  on 
from  this  glandular  focus  until  in  favorable  cases  the  bacilli 
cease  to  multiply  and  the  focus  heals ;  and  in  less  favorable  con- 
ditions, although  healing  may  not  occur,  yet  the  multiplication 
of  bacilli  is  usually  checked  and  the  activity  of  the  disease  pro- 
cess held  in  abeyance  for  a  time. 

The  child,  coming  in  contact  with  tubercle  bacilli,  usually 
meets  them  at  first  in  small  numbers,  and  is  able  to  overcome 
them;  or,  at  least  to  confine  the  infection  to  one  of  mild  degree. 
Where  an  infection  has  resulted  and  been  confined  to  a  small 


CELL  SENSITIZATION  AND   METASTASES  35 

focus,  whether  this  heals  or  not,  the  organism  develops  such  a 
degree  of  immunity,  that  is,  the  cells  develop  such  a  power  of 
specific  defense  that  it  is  able  to  defend  itself  almost  wholly  from 
further  infection  from  without.3  Koch's  original  experiment 
showing  that  whereas  a  healthy  guinea  pig  infected  with  tubercle 
bacilli,  shows  a  ready  absorption  of  the  bacilli  and  an  infection 
of  the  regional  lymph  glands,  while  one  which  was  previously 
tuberculous,  shows  a  resistance  to  infection,  a  local  ulcer  form- 
ing, the  bacilli  being  expelled  and  the  regional  lymph  glands  re- 
maining unaffected,  confirms  this. 

Secondary,  or  metastatic  infections,  such  as  those  affecting 
the  lungs,  are  for  the  most  part  believed  to  be  due  to  bacilli 
escaping  from  some  previous,  usually  lymphatic,  focus.  Here, 
too,  we  must  suppose  that  the  number  of  bacilli  escaping  is 
usually  small,  and  that  most  of  them  are  destroyed  without  an 
infection  occurring.  The  probabilities  are  that  if  they  are  not 
destroyed  while  coursing  in  the  blood  stream,  they  are  reduced 
in  virulence.  Many  of  them,  we  assume,  are  destroyed  as  a  re- 
sult of  their  stimulation  of  the  sensitized  cells  to  the  produc- 
tion of  specific  protective  ferments,  as  soon  as  they  are  enmeshed 
in  the  pulmonary  tissues.  However,  now  and  then,  regardless 
of  the  specific  cellular  defense  (immunity)  present,  an  infection 
will  occur.  This  metastatic  focus,  as  a  rule,  is  small  and  single ; 
the  exception  being  when  a  large  number  of  bacilli  have  made 
their  escape  from  the  lymphatic  focus,  such  as  occurs  when  soft- 
ening of  a  large  tubercle  takes  place  with  rupture  into  a  blood 
vessel,  producing  either  a  localized  or  a  general  dissemination 
(miliary  tuberculosis). 

The  body  fluids  containing  antibodies,  the  pulmonary  cells 
being  specifically  sensitized  and  the  number  of  invading  bacilli 
being  small,  the  early  metastases,  as  a  rule,  do  not  make  rapid 
progress.  They  are  fibroid  in  form.  They  often  amount  to  no 
more  than  a  nodule  which  can  be  found  only  by  most  careful 
search;  at  times,  however,  the  infection  is  more  widespread  and 
yet  results  in  new  tissue  formation.  Occasionally,  however,  the 
primary  metastasis  will  be  transformed  into  an  area  of  necrosis, 
either  small  or  large,  which  may  either  become  calcified  and  re- 
main quiescent,  or  rupture,  leaving  an  open  ulcerating  surface, 

8Romer:     Brauer's  Beitrage  zur  Tuberkulose,  Bd.  xiii,  xvii,  and  xxii. 


36  PATHOLOGICAL.   CHANGES  IN   TUBERCULOSIS 

this  again  to  heal  or  remain  as  a  focus  from  which  further 
metastases  may  form. 

These  primary  foci  in  the  lung  often  become  encapsulated  with 
bacilli  enclosed;  and,  while  the  bacilli  may  go  on  to  death,  yet 
at  times  they  remain  alive  and  sooner  or  later,  for  some  cause 
which  we  do  not  understand,  begin  to  multiply  and  produce  ac- 
tivity in  the  focus  of  infection.  Von  Pirquet  has  assumed  that 
at  times  the  body  takes  upon  itself  a  condition  wherein,  tem- 
porarily, it  loses  its  specific  defense  against  bacilli,  and  in  this 
way  he  accounts  for  the  renewed  activity  in  old  quiescent  foci. 
This  condition  has  been  termed  "anergie"  by  him.  Any  focus 
which  has  not  thoroughly  healed  with  destruction  of  the  bacilli, 
may  be  a  source  of  further  dissemination  of  the  disease. 

From  these  primary  metastatic  foci  the  disease  may  spread  at 
once  or  later,  either  by  way  of  adjacent  lymph  spaces  or  small 
bronchi;  pushing  out  into  the  adjoining  tissues  and  gradually 
involving  more  and  more  of  the  lung.  The  extension  usually 
takes  place  downward  from  the  apex.  Should  the  bacilli  gain 
access  to  the  blood  stream,  metastasis  may  occur  in  distant 
portions  of  the  lungs  or  even  distant  parts  of  the  body.  But  the 
general  rule  is  for  tuberculosis  to  extend  contiguously. 

The  first  pulmonary  metastasis  of  hemotogenous  origin  usually 
occurs  near  the  apex,  nearly  always  above  the  third  rib.  This 
is  the  same  area  that  usually  shows  infection  of  the  pleura. 
Aside  from  these  areas  there  is  often  a  primary  infection  of 
those  pulmonary  and  pleural  tissues  which  are  contiguous  to  the 
bronchial  glands,  the  infection  apparently  extending  against  the 
lymph  stream  into  the  tissue. 

Lymphogenous  Metastasis. — The  spreading  of  pulmonary  tuber- 
culosis through  the  lymphatics  is  of  special  import.  It  is  prob- 
able that  bacilli  are  carried  by  the  wandering  cells.  Some  au- 
thors attribute  great  importance  to  this  method  of  spread. 
Again,  it  may  spread  through  the  lymph  spaces.  In  this  con- 
nection it  is  necessary  to  understand  the  influence  of  respira- 
tion in  both  the  healthy  and  diseased  lung.  Every  inspiration 
increases  the  pulmonary  area  and  widens  the  intrapulmonary 
lymph  spaces;  every  expiration  lessens  the  pulmonary  area  and 
narrows  the  lymph  spaces.  By  this  succession  of  enlarging  and 
narrowing  the  lymph  spaces,  the  fluid  is  moved  back  and  forth 


LYMPHOGENOUS  AND  BRONCHOGENOUS   METASTASES  37 

through  the  pulmonary  tissues.  Not  only  is  the  lymph  forced 
toward  the  larger  lymphatic  trunks  and  regional  glands,  but  it 
can  easily  be  seen  that  it  might  be  forced  backwards  as  well. 
This  occurs  often;  and  it  is  now  generally  conceded  that  bacilli 
may  be  forced  onward  in  the  general  direction  of  the  lymph  flow 
or  backward  against  the  stream  (Tendeloo).  Another  point  of 
great  interest  is  that  there  is  a  wide  difference  in  the  lymph  flow 
in  various  portions  of  the  lungs,  also  in  the  healthy  as  compared 
with  the  tuberculous  lung.  The  motion  of  the  chest  wall  and 
diaphragm  is  lessened  on  the  affected  side.  The  respiratory  ef- 
fort is  restricted  and  consequently  the  flow  of  lymph  is  retarded 
throughout  the  organ,  a  condition  which  favors  the  implanta- 
tion of  bacilli  in  the  lymph  spaces. 

Lymphatic  metastases  are  often  found  in  the  glands  of  the  lung, 
the  lymph  spaces  surrounding  the  bronchi  and  vessels  and  the 
subpleural  spaees. 

The  fact  that  tubercle  bacilli  may  be  carried  against  the  lymph 
stream  assumes  special  importance  in  connection  with  the  theory 
of  certain  authors  that  infection  travels  from  the  hilus  toward 
the  apex. 

The  conditions  which  favor  lymphatic  metastases  are  the  col- 
lateral inflammation  and  the  restricted  motion  of  the  part. 
These  are  accompanied  by  injury  of  the  tissue  and  a  retarded 
lymph  flow.  If  only  a  few  bacilli  escape  into  the  adjacent  lymph 
spaces  the  resulting  infection  may  be  mild,  but,  if  the  numbers 
are  great  the  best  conditions  possible  are  present  for  an  extreme- 
ly virulent  metastasis. 

Bronchogenous  Metastasis. — While  the  lessened  motion  of  the 
diseased  lung  together  with  the  stasis  dependent  upon  the  col- 
lateral inflammation  favor  lymphatic  spread  of  the  disease,  it 
lessens  the  danger  of  spread  by  the  bronchi.  This  latter  is  a 
very  common  form  of  spreading  of  the  disease  in  open  dases. 
When  the  disease  has  passed  to  the  point  of  softening  and  cav- 
ity formation,  the  air  passages  are  always  exposed  to  the  danger 
of  infection  from  this  source.  Deep  breathing  and  coughing  has 
a  tendency  to  force  the  bacillus-bearing  sputum  into  areas  not 
already  infected,  to  plug  the  bronchus  with  infectious  mucus, 
thus  starting  up  new  foci  of  infection.  When  bacilli  are  im- 
planted upon  the  tissues  through  the  bronchial  route,  they  do 


38  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

not  affect  the  epithelium  of  the  air  passages,  but  pass  through 
the  mucous  membrane  and  settle  in  the  subepithelial  cells.  This 
type  of  the  disease  is  apt  to  be  very  virulent.  This  is  the  usual 
method  of  infection  in  circumscribed  caseous  pneumonias. 

Hematogenous  Metastasis. — Hematogenous  metastasis  shows 
many  variations.  It  has  been  proved  recently  that  tuberculosis 
is  at  times  a  bacillemia.  Bacilli  often  pass  into  the  blood  stream ; 
and  they  can  be  recovered  in  a  large  per  cent  of  patients  suf- 
fering from  the  advanced  form  of  the  disease.  When  only  a  few 
bacilli  enter  the  blood  stream,  they  are  destroyed  without  an  in- 
fection resulting;  when  the  number  is  larger  they  may  with- 
stand the  effects  of  the  antibacillary  elements  in  the  blood,  like- 
wise the  specific  defensive  properties  of  the  cells  in  which  im- 
plantation occurs  and  form  a  new  focus;  when  still  larger  the 
bacilli  may  be  in  such  numbers  that  they  heap  up,  blocking  the 
capillaries  of  either  a  particular,  limited  area  supplied  by  a 
certain  small  blood  vessel  and  its  branches  or  of  a  large  area 
of  the  body  supplied  by  a  very  large  vessel,  causing  acute  gen- 
eral miliary  tuberculosis. 

The  hematogenous  form  of  spreading  accounts  for  the  infec- 
tion of  an  organ  distant  from  the  primary  focus.  Thus,  such 
lesions  as  those  of  the  bones,  joints,  meninges,  and  kidneys  oc- 
cur when  the  primary  focus  is  in  the  mediastinal  glands  or  lung. 

Ordinarily,  except  in  acute  miliary  tuberculosis,  the  lesions 
which  are  caused  by  spreading  through  the  blood  are  of  a  mild, 
non-virulent  type.  This  is  probably  due  to  the  fact  that  bacil- 
li, entering  the  blood  stream,  come  in  contact  with  the  specific 
antibacillary  substances  so  intimately  that  while  not  wholly  de- 
stroyed, their  virulence  is  greatly  reduced,  and,  further,  they 
are  so  scattered  by  the  flowing  blood  that  the  infection  which 
occurs  is  formed  by  few  bacilli.  Widespread  fibroid  tuberculosis 
is  produced  in  this  same  manner. 

There  has  been  much  speculation  on  the  part  of  students  of 
tuberculosis  in  trying  to  explain  why  the  areas  above  the  third 
rib,  and  particularly  those  toward  the  vertebrae,  are  more  prone 
to  infection  than  other  portions  of  the  lung.  The  plausible  ex- 
planation is  that  these  areas  naturally  have  less  motion  than 
other  parts  of  the  lung,  consequently,  have  a  comparative  retard- 
ing effect  on  the  blood  and  lymph  flow  which,  in  turn,  favors  the 


Fig.  7. — Miliary  tuberculosis  of  the  lung.      (Tendeloo.) 


LOCALIZATION   OF  PULMONARY   TUBERCULOSIS  39 

heaping  up  of  bacilli  in  the  capillaries  and  lymph  spaces,  thus 
favoring  infection.  If,  however,  it  were  the  lessened  motion 
alone  which  favors  infection,  the  disease  would  be  most  com- 
mon at  or  near  the  hilus  for  it  is  at  that  point  that  the  lung 
shows  the  least  motion;  but  implantation  is  not  favored  at  this 
point,  either  by  way  of  the  lymph  or  blood  because  the  lymphatic 
trunks  are  larger  and  the  capillary  network  is  not  as  extensive 
as  in  the  apex.  It  does  occur,  however,  at  times,  as  is  shown  by 
x-ray  examination. 

Freund,  Schmorl  and  Rothschild  have  found  certain  conditions 
about  the  upper  aperture  of  the  thorax  which  they  have  de- 
scribed as  being  causative  factors  in  the  production  of  tubercu- 
losis. Freund  has  found  a  shortening  of  the  first  rib  and  ossifi- 
cation of  the  first  costal  cartilage  in  many  cases  of  tuberculosis 
and  believes  that  these  conditions  act  mechanically.  This  has 
been  strongly  supported  by  Hart.  Schmorl  has  described  fur- 
rows near  the  apex  which  he  believes  retard  the  flow  of  lymph 
and  blood.  Rothschild  has  found  that  there  is  a  diminution  of 
action  in  the  manubrio-sternal  joint  in  tuberculosis  and  described 
it  as  a  predisposing  cause.  These  theories  fail  to  take  certain 
facts  into  consideration.  If  the  compression  of  the  rib,  or  the 
furrow,  or  the  lack  of  motion  of  the  manubrio-sternal  joint  were 
the  particular  predisposing  causes  of  underlying  tuberculosis  of 
the  apex,  we  would  expect  the  disease  to  begin  in  that  portion 
of  the  lung  most  affected  by  such  compression,  namely,  the  an- 
terior surface;  but  such  is  not  the  case.  The  disease  usually 
begins  posteriorly  and  near  the  vertebral  column.  Aside  from 
this  failure  to  conform  to  the  facts  of  the  localization  of  the 
disease,  a  more  plausible  explanation  can  be  offered  depending 
upon  the  anatomical  differences  incident  to  development  and 
growth.  In  this  connection  I  would  refer  the  reader  to  Chap- 
ter V  which  treats  of  this  subject  more  fully. 

Forms  of  Tuberculosis. — Tuberculosis  presents  many  differ- 
ent clinical  pictures  but  there  is  no  particular  advantage  in 
treating  each  as  a  separate  entity.  Pathologically  we  may 
classify  the  disease  into  those  forms  which  have  a  tendency  to 
produce  new  tissue,  those  in  which  destruction  of  tissue  is  the 
predominant  factor,  and  the  combination  of  these  two. 

Miliary  Tuberculosis. — Miliary  tuberculosis  (Fig.  7),  as  previ- 


40  PATHOLOGICAL   CHANGES   IN   TUBERCULOSIS 

ously  mentioned,  is  caused  by  bacilli  being  thrown  into  the 
blood  or  lymph  stream  in  large  numbers.  It  is  characterized  by 
new  tissue  formation.  There  may  be  a  large  or  small  area  in- 
volved. The  tubercles  throughout  the  area  infected  are  of  the 
same  age  and  size  having  come  from  the  same  inoculation.  Mili- 
ary tuberculosis  may  affect  any  organ.  We  see  it  in  the  lungs, 
spleen,  liver,  kidney,  meninges,  and  peritoneum.  If  extensive, 
or  if  it  affects  a  vital  organ  it  is  usually  fatal  in  a  short  time. 
It  may  be  generalized  and  affect  many  organs.  One  patient  un- 
der my  care,  with  miliary  disease  of  the  lungs,  died  on  the 
twenty-first  day  after  the  onset  of  symptoms.  Miliary  disease 
of  the  lung  often  produces  death  before  the  tubercles  soften.  It 
may  be  a  primary  metastatic  disease  coming  from  some  caseous 
focus  in  a  patient  who  has  been  previously  healthy,  and  ap- 
parently free  from  disease;  or  it  may  follow  the  breaking  of  a 
necrotic  mass  into  the  blood  stream  in  chronic  tuberculosis.  I 
have  seen  it  follow  hemorrhages  in  a  number  of  instances,  suf- 
ficient bacilli  gaining  access  to  the  blood  stream  to  cause  a  gen- 
eralized miliary  condition  and  a  rapidly  fatal  issue. 

Fibroid  Tuberculosis. — Fibroid  tuberculosis  is  another  form  of 
the  disease  characterized  pathologically  by  the  formation  of 
new  tissue.  This  disease  is  usually  chronic  in  character  being 
produced  by  bacilli  of  low  virulence.  It  is  of  hematogenous 
origin  and  the  low  virulence  may  be  due  to  the  fact  that  the 
bacilli  are  diluted,  that  their  virulence  has  been  reduced  by 
the  antibodies  with  which  they  have  come  in  contact  in  the 
blood  stream  and  the  fact  that  the  cells  are  endowed  with  the 
property  of  producing  specific  defensive  enzymes  before  inocu- 
lation has  occurred,  as  previously  mentioned.  The  primary 
metastatic  focus  in  nearly  all  organs  is  small  in  extent  and 
fibroid  in  character,  regardless  of  the  form  which  the  disease 
may  assume  later. 

The  virulence  of  the  infecting  bacilli  in  fibroid  tuberculosis  is 
so  low  that  a  very  small  amount  of  toxins  are  thrown  out,  con- 
sequently the  tissues  are  irritated  but  not  destroyed.  This  type 
is  accompanied  by  a  very  mild  collateral  inflammation.  The 
production  of  new  granulation  tissue  results  (Fig.  8).  Some- 
times this  is  very  rich  in  blood  vessels  and  results  in  large 
bundles  of  new  tissue  which  later  on  are  converted  into  hard 


Fig.    8. — Illustrating   pulmonary    tuberculosis,    with    thickened   pleura,    many    bronchiectatic 
cavities,  and  generalized  cavity  formation.      (Tendeloo.) 


Fig.   9. — Sacculated  bronchiectasis.      (Powell   and  Hartley.) 


TYPES   OF  TUBERCULOSIS  41 

scar  which  contracts  and  if  extensive  causes  a  great  deformity 
of  the  organ.  Resulting  from  the  extensive  contraction  the 
lung  becomes  smaller.  In  order  to  compensate  for  the  loss  on 
the  part  of  the  affected  lung,  the  other  lung  and  the  portions 
of  the  same  lung  which  are  not  affected  by  the  fibrosis,  become 
emphysematous,  the  mediastinum  draws  toward  the  contracted 
side  and  all  the  thoracic  organs  are  compelled  to  adjust  them- 
selves to  new  conditions,  as  described  fully  in  Chapter  XI. 

Pouching  of  the  bronchi  may  take  place  as  a  result  of  the  ir- 
regular contraction  causing  a  condition  of  bronchiectasis  (Figs. 
8  and  9). 

This  form  of  tuberculosis  is  accompanied  by  extensive  connec- 
tive tissue  formation  and  the  bacilli  are  well  walled  in.  Many 
of  them  die.  Others  remain  living  but  are  rendered  harmless. 
After  a  time,  for  some  unexplainable  reason,  bacilli  which 
have  been  shut  up  in  the  scar  tissue  and  which  have  remained 
in  a  state  of  inactivity  may  develop  an  increased  virulence.  They 
multiply,  produce  toxins  which  are  followed  by  necrosis  and 
the  conversion  of  the  process  into  an  ulcerative  one.  This  is 
the  course  which  many  of  the  fibroid  lungs  eventually  follow. 

Caseous  Tuberculosis. — Caseous  tuberculosis  (Fig.  10),  is  that 
form  of  the  disease  in  which  degenerative  processes  predomi- 
nate. This  form  presupposes  a  virulent  strain  of  bacilli  and  bio- 
chemical conditions  of  the  tissues  favorable  to  their  rapid  mul- 
tiplication. These  conditions  result  in  a  rapid  development  of 
toxins,  with  extensive  necrosis,  and  a  wide  spread  severe  collat- 
eral inflammation.  Acute  tuberculosis,  the  so-called  "gallop- 
ing consumption,"  and  acute  pneumonic  tuberculosis  are  of 
this  type.  These  forms  of  the  disease  are  characterized  patho- 
logically by  rapid  destruction  of  tissue  with  cavity  formation 
if  the  patient  lives  long  enough  and  little  or  no  tendency  to  con- 
nective tissue  formation.  If  the  process  is  extensive,  marked 
toxemia  and  such  a  state  of  malnutrition  accompanied  by  de- 
generative changes  in  the  various  organs  occurs  that  the  patient 
soon  succumbs.  If,  on  the  other  hand,  the  process  is  confined  to 
a  lobe  or  a  portion  of  a  lobe,  the  necrotic  tissues  may  be  ex- 
pelled, a  cavity  resulting  with  relief  of  the  toxemia  and  improve- 
ment of  the  patient.     This  is  not  an  uncommon  result. 

Fibro-Caseous  Tuberculosis. — This  is  the  most  common  type  of 


42  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

pulmonary  tuberculosis  met  clinically.  It  is  the  usual  form  of 
chronic  clinical  tuberculosis.  It  consists  of  areas  of  necrosis 
which  rupture  and  are  thrown  off  leaving  cavities;  a  collateral 
inflammation  of  a  moderate  degree;  and  a  tendency  to  the  pro- 
duction of  new  tissue  in  the  areas  which  are  the  seat  of  tuber- 
cles which  have  not  yet  gone  on  to  necrosis  and  softening;  and 
further,  a  tendency  to  the  formation  of  connective  tissues  about 
the  walls  of  the  cavities.  In  some  patients  the  necrosis  and  ul- 
cerative process  predominates;  in  others  the  fibrosis.  The 
process  is  chronic,  and  when  progressive,  gradually  spreads  from 
the  apex  downward  toward  the  bases  of  the  lungs.  The  great- 
est number  of  cavities  is  usually  near  the  apex.  Another  fav- 
ored seat  is  the  apex  of  the  lower  lobe,  although  any  portion  of 
the  lungs  may  be  the  seat  of  cavity.  Cavities  at  the  apices  of 
the  lungs  are  much  more  favorable  for  healing  than  those  in 
the  lower  lobes  because  they  are  kept  clean  with  greater  ease, 
drainage  being  in  their  favor.  The  prognosis  of  this  type  de- 
pends much  on  the  extent  of  the  lesion  and  as  to  whether  ul- 
ceration or  fibrosis  predominates.  Sometimes  an  ulcerative 
process  will  predominate  at  first  and  fibrosis  later,  which  usually 
means  a  retardation  or  an  arrestment  of  the  process ;  sometimes 
the  reverse  is  true,  which  means  progression  and  ultimate  loss 
of  life. 

This  form  of  tuberculosis,  if  an  arrestment  occurs,  often 
shows  even  more  marked  contraction  and  compensatory  changes 
with  greater  shifting  of  the  mediastinum  and  diaphragm  than 
the  more  purely  fibroid  form. 

Non-tuberculous  Changes  in  Other  Organs. — In  chronic  pul- 
monary tuberculosis  there  are  changes  in  the  various  organs 
of  a  non-tuberculous  character  which  prove  to  be  extremely 
important  from  the  standpoint  of  prognosis,  and  which  must 
not  be  neglected  in  therapy. 

Pulmonary  tuberculosis,  after  it  has  reached  the  chronic 
stage  (consumption)  cannot  be  looked  upon  as  merely  a  disease 
of  the  lungs.  It  is  a  disease  of  the  lungs  caused  by  the  im- 
plantation of  the  tubercle  bacillus,  plus  all  secondary  changes 
resulting  from  and  accompanying  such  infection;  plus  all  the 
disturbances  of  function  on  the  part  of  the  other  organs  of  the 
body  which  result  from  the  changes  in  the  lungs  and  from  the 


Fig.    10.— Illustrating  caseous   tuberculosis.      Large   cavities   at  the  apex   and   many   small 
cavities  throughout  the  lung.      (Tendeloo.) 


NON-TUBERCULOUS   DEGENERATIONS  43 

specific  toxemia  and  the  malnutrition    which,    accompany    the 
disease. 

Degeneration. — There  are  three  degenerative  changes  which 
are  commonly  found  in  the  bodies  of  those  who  die  from  chronic 
ulcerative  tuberculosis,  amyloid,  fatty,  and  cloudy  swelling. 
These  three  forms  of  degeneration  involve  different  tissues,  but 
in  their  selection  leave  few  if  any  tissues  unaffected. 

These  degenerations  are  usually  explained  as  being  due  to  the 
effect  of  toxins  and  malnutrition.  Just  how  these  factors  act  is 
not  perfectly  clear.  Our  knowledge  of  the  degenerations  of 
the  structures  which  are  affected  by  reflex  stimulation  as  il- 
lustrated in  the  regional  degeneration  of  the  skin,  subcutaneous 
tissue  and  muscles,  offers  a  basis  for  thinking  that  probably  the 
same  degenerative  tendency  might  be  found  wherever  tissues 
stand  in  a  relationship  to  be  affected  reflexly  by  impulses  cours- 
ing from  the  lung.  If  so,  then  we  are  led  to  the  conclusion  that 
all  organs  which  stand  in  such  a  relationship  with  the  pulmon- 
ary branches  of  the  vagus  and  possibly  also  of  the  sympathetic 
divisions  of  the  vegetative  system  might  be  so  affected.  Further, 
realizing  that  toxins  stimulate  the  sympathetics  centrally,  we  have 
a  double  stimulation  of  this  division  which  tends  to  produce  the 
same  effect.  In  this  connection,  the  studies  of  Crile4  show  that 
continuous  stimulation  of  nerves  by  such  stimuli  as  depressive  emo- 
tional states,  pain  and  toxemias,  produce  changes  in  the  higher 
center.  It  seems  that  the  way  is  now  open  so  that  we  may  go  a 
step  further  than  to  say  that  toxemias  and  malnutrition  are  the 
causes  of  degenerations;  and  suggest  that  the  cause  which  oper- 
ates to  produce  them,  acts,  at  least  partially,  through  the  vege- 
tative nervous  system.  To  this  we  must  also  add  the  possibility 
of  degeneration  resulting  from  changes  coming  from  the  chem- 
ical stimuli  which  are  produced  by  altered  internal  secretions. 
The  work  of  Fisher  in  showing  that  the  equilibrium  which  main- 
tains tissue  stability  is  easily  changed,  suggests  this  as  an  im- 
portant factor. 

Amyloid  Degeneration. — Amyloid  degeneration,  or  waxy  de- 
generation as  it  is  called,  affects  connective  tissue  and  blood 
vessels.  By  a  gradual  change  the  small  arteries  and  capillaries 
are  involved;  their  walls  are  thickened  and  later  become  obliter- 


<The  Origin  and  Nature  of  Emotions,  W.  B.   Saunders  Company,  Philadelphia,  1915. 


44  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

ated,  thus  destroying  the  function  of  the  part.  The  effect  de- 
pends upon  the  size  of  the  vessel  or  the  number  of  vessels  in- 
volved. Amyloid  degeneration  shows  in  the  liver,  spleen,  kid- 
neys, and  intestinal  tract.  The  affected  organs  are  larger  than 
normal. 

Fatty  Degeneration. — Fatty  degeneration  has  a  special  pred- 
ilection for  epithelial  cells.  Whether  this  is  a  true  degenera- 
tion, or  simply  a  deposit  of  fat,  is  not  yet  decided.  This  de- 
generation often  shows  to  a  high  degree  in  the  liver,  kidney 
and  heart  of  those  suffering  from  tuberculosis.  Fatty  degen- 
eration may  be  extensive  and  not  interfere  greatly  with  func- 
tion. In  connection  with  the  solution  of  the  cause  of  this  de- 
generation, I  desire  to  call  attention  to  Fisher's  recent  studies 
on  the  chemistry  of  tissues. 

Cloudy  Swelling. — Cloudy  swelling  of  glandular  epithelium 
is  common  in  advanced  tuberculosis. 

General  Congestion. — A  varying  degree  of  congestion  is  pres- 
ent in  many  of  the  organs  in  advanced  tuberculosis.  This  shows 
in  a  cyanosis  of  the  skin  and  as  a  general  congestion  of  many 
other  organs,  particularly  those  in  the  abdominal  cavity.  This 
congestion  may  be  the  result  of  an  extensive  active  process 
in  the  lung,  a  contraction  affecting  a  large  area  of  lung  tissue, 
or  marked  pleural  adhesions.  Conditions  which  seriously  affect 
the  action  of  the  diaphragm  result  in  a  deficient  expansion  of 
the  chest,  thus  failing  to  furnish  the  normal  suction  action  which 
draws  the  blood  to  the  heart.  This  results  in  a  damming  back  of 
the  blood  in  the  veins.  This  shows  especially  in  the  splanchnics 
which  are  markedly  congested.  As  a  result  of  this,  we  have 
many  of  the  disturbances  of  function  which  are  noted  clinically 
in  advanced  tuberculosis.5 

Changes  in  Nerves. — Changes  in  nerves  are  also  noted  in  tu- 
berculosis. Aside  from  the  general  effect  of  toxins  upon  the 
nervous  system  as  a  whole,  changes  take  place  in  the  particular 
nerves  which  take  their  origin  from  the  segments  of  the  cord 
which  receive  the  impulses  from  the  diseased  pulmonary  tissue. 
This  is  evident  clinically,  although  it  has  not  been  reported  on 
in    detail    pathologically.      This    irritation    clinically    at    times 


6Pottenger:      Enteroptosis    and    Altered    Function    of    the    Diaphragm    Resulting    from 
Intrathoracic  Inflammations,  New  York  Medical  Journal,  December  16,  1911. 


CHANGES  IN   MUSCLES,   SKIN,   AND  BLOOD  VESSELS  45 

amounts  to  a  marked  neuritis.6  Since  first  noting  this,  nine  cases 
of  brachial  neuritis  all  on  the  side  of  the  lung  with  the  severest 
process,  have  come  under  my  observation.    See  page  163. 

Changes  in  Muscles. — Changes  in  the  muscles7  are  found  not 
only  as  a  result  of  the  general  malnutrition  and  toxemia,  but 
as  a  result  of  a  regional  reflex.  The  reflex  degenerative  changes 
found  in  these  muscles  were  described  as  follows:  "One  finds  in 
such  muscles  both  degenerative  and  regenerative  changes.  Some- 
times the  stripes  are  indistinct  and,  at  times,  they  are  entirely 
wanting.  The  fibers  take  the  stain  poorly  and  in  some  instances 
are  destroyed.  In  many  preparations  one  sees  an  increase  in 
the  nuclei  of  the  cells  and  slight  signs  of  regeneration." 

This  change,  as  noted  clinically,  is  an  increased  tension  when 
the  disease  in  the  chest  is  acute  and  a  flabbiness  of  the  mus- 
cles when  the  inflammation  has  once  passed  over  into  the 
chronic  state. 

This  follows  the  same  law  as  just  mentioned  in  describing 
the  changes  in  the  nerves  and  is  first  a  response  to  the  stimula- 
tion from  the  irritated  nerve  and  secondarily  a  degeneration  re- 
sulting from  overwork  or  the  disturbance  of  the  trophic  im- 
pulses. 

Changes  in  the  Skin  and  Subcutaneous  Tissue. — Atrophy  of 
the  skin  and  subcutaneous  tissue  takes  place  as  a  result  of  re- 
flex segmental  irritation,  the  same  as  occurs  in  the  muscles. 
This  is  regional  in  character  and  is  entirely  separate  from  the 
general  degeneration  which  occurs  in  chronic  tuberculosis. 

Changes  in  Blood  Vessels. — Changes  in  blood  vessels  are  also 
common  and  of  vast  importance  from  the  clinical  standpoint. 
As  mentioned  above,  amyloid  degeneration  affects  the  vessels  of 
the  various  organs,  such  as  the  kidney,  liver,  spleen,  pancreas 
and  intestines  and  interferes  with  their  proper  function.  As  a 
result  of  toxic  irritation,  the  same  as  is  noted  after  typhoid 
(Thayer),  a  thickening  takes  place  in  the  arteries,8  as  noted  on 
palpation  of  the  radials.    This  shows  itself  especially  in  chronic 


6Pottenger:  Chest  and  Shoulder  Pains  in  Tuberculosis,  Transactions  of  the  American 
Climatological    Association,    1912. 

7Pottenger:  A  New  Physical  Sign  Found  in  the  Presence  of  Inflammation  of  the 
Lungs  and  Pleura,  Journal  of  the  American  Medical  Association,  March  6,  1909;  and 
"Die  Rigiditat  der  Muskeln  und  die  leichte  Tastpalpation  als  wichtige  Zeichen  zur  Erken- 
nung  der  Lungenkrankheiten,"   Deutsche  Medizinische  Wochenschrift,   Nr.    16,    1910. 

8Pottenger:  The  Effect  of  Tuberculosis  on  the  Heart,  Archives  of  Internal  Medicine, 
October,    1909,   vol.   iv.   p.    306. 


46  PATHOLOGICAL   CHANGES   IN   TUBERCULOSIS 

tuberculosis  when  the  disease  has  existed  for  a  long  time  and 
been  pouring  out  toxins  in  small  quantities  over  a  period  of 
months  or  years.  The  arteries  are  often  smaller  than  normal, 
as  has  been  mentioned  by  Martius9  and  Beneke,10  as  a  predis- 
posing factor  in  infection,  but  which  I  have  explained  as  being 
a  result  of  the  diminished  inspiratory  act  resulting  from  the  dis- 
ease.   See  page  301. 

Tubercle  bacilli  often  invade  the  vessel  walls  both  from  with- 
in and  without,  and  not  uncommonly  tubercles  form  within  the 
walls  and  rupture,  causing  hemorrhage.  At  other  times  this 
rupture  allows  bacilli  to  escape  into  the  lumen  and  scatter  in- 
fection by  way  of  the  blood  stream.  If  many  bacilli  escape  at 
one  time,  generalized  miliary  tuberculosis  results;  if  a  few,  soli- 
tary or  multiple  tubercles  form. 

Non-pulmonary  Tuberculosis. — Many  organs  and  tissues  out- 
side of  the  lungs  are  at  times  affected  with  tuberculosis,  the 
process  being  one  which  either  complicates  a  pulmonary  in- 
fection or  one  entirely  independent  of  it.  The  pathology  of 
these  various  lesions  is  the  same  except  as  the  process  adapts 
itself  to  the  peculiar  characteristics  of  the  different  kinds  of 
tissue  in  which  it  is  found. 

Nasal,  Lingual,  Tonsillar,  and  Pharyngeal  Tuberculosis. — Tu- 
berculous processes  are  occasionally  found  in  the  nasal  mucous  mem- 
branes, tonsils,  pharynx  and  tongue,  and  quite  often  in  the  larynx. 
These  may  be  either  proliferative,  degenerative  or  mixed  in  char- 
acter. Lesions  of  the  nasal  mucous  membranes,  pharynx  and 
tonsil  in  the  writer's  experience  have  been  for  the  most  part 
of  the  degenerative  type  and  have  shown  little  tendency  to 
heal.  Lesions  of  the  tongue  have  been  for  the  most  part  of  the 
proliferative  type  with  marked  tendency  to  heal;  while  lesions 
of  the  larynx  have  been  of  the  degenerative,  proliferative  and 
mixed,  and,  as  a  rule,  have  shown  a  tendency  to  heal  in  nearly 
all  instances  where  the  disease  in  the  lung  was  taking  a  favor- 
able course.  Figs.  11A  and  11B  illustrate  two  tuberculous  ulcers 
on  the  tongue  of  the  same  individual  which  healed  after  two  and 
one-half  years'  treatment.    Fig.  110  shows  an  ulcer  on  the  dorsum 


9Pathogenese  innere  Krankheiten. 

10Quoted  by  Sokolowski,  Klinik  der  Brustkrankheiten,  Berlin,  1906,  vol.  ii,  p.  237. 


Fig.  11. — Illustrating  tuberculous  lesions  of  the  tongue,  A  and  B  in  the  same  individual, 
healing  after  two  and  one-half  years'  treatment;  C,  on  the  dorsum  of  the  tongue  of  an 
individual  suffering  from  active  advanced  tuberculosis;  no  signs  of  healing  shown,  patient 
dying  of  the  disease  a  few  months  later. 


LARYNGEAL   TUBERCULOSIS  47 

of  the  tongue  which  failed  to  heal,  the  patient  dying  of  advanced 
tuberculosis. 

I  have  never  seen  a  primary  lesion  affecting  any  of  these  tis- 
sues, although  such  is  sometimes  reported  in  literature,  and  is 
possible. 

Laryngeal  Tuberculosis. — Any  portion  of  the  larynx  may  be 
the  seat  of  tuberculous  infiltration  and  ulceration.  The  focus 
is  usually  subepithelial  in  character  but  may  be  deeper  in  the 
tissues.  The  lesion  may  be  slight  or  it  may  be  accompanied  by 
an  extensive  destructive  process.  It  may  show  either  as  an  in- 
filtration or  ulceration.  The  most  serious  processes  are  peri- 
chondritis and  chondritis,  which  often  lead  to  softening  and 
purulent  degeneration. 

The  interarytenoid  space,  the  arytenoids,  and  the  cords  are 
the  most  common  seats  of  infection.  This  represents  two  dif- 
ferent types  of  tissue,  the  arytenoid  region  being  extremely  well 
supplied  with  lymphatics  while  the  cords  are  not.  In  61  cases 
reported  by  the  writer,11  the  arytenoid  region  and  the  cords 
were  affected  45  times  or  in  73.77  per  cent.  Besold's  cases12 
showed  316,  or  63  per  cent  infections  of  the  arytenoid  region 
and  cords  in  498  cases. 

Tuberculosis  of  the  larynx  is  nearly  always  secondary.  Cases 
are  now  and  then  diagnosed  as  primary  because  of  a  failure  to 
discover  the  original  focus.  The  fact  that  the  disease  is  practi- 
cally always  found  as  a  complication  of  pulmonary  tuberculosis 
suggests  that  this  organ  is  not  a  natural  site  for  the  disease  as 
it  spreads  through  the  body  by  means  of  the  blood.  It  also 
suggests  that  the  infecting  bacilli  come  from  the  lesion  in  the 
lung,  whether  by  way  of  the  lymphatics,  or  by  direct  infection 
from  sputum  is  not  determined.  Richard  Lake13  takes  the  view 
that  the  mode  of  entry  is  nearly  always  by  surface  infection  and 
states  that  there  is  no  direct  lymphatic  connection  to  which  the 
infection  can  be  traced.  It  would  seem  that  this  view  is  ra- 
tional; and  it  harmonizes  with  the  idea  of  the  secondary  infec- 
tion of  the  intestines  being  of  surface  origin. 

Tuberculosis  of  the  larynx  is  common.     Postmortems  reveal 


"Prognosis    and    Treatment    of    Tuberculous    Laryngitis:      An    Analysis    of    Sixty-one 
Cases,    California    State    Journal    of    Medicine,    October,    1908. 
12Besold  and  Gideonson:  Pathologie  und  Therapie  der  Kehlkopftuberkulose,  Berlin,  1907. 
"Laryngeal  Tuberculosis,  William  Wood  &  Company,  New  York,  190S. 


48  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

laryngeal  infection  in  about  50  per  cent  of  those  dying  of  tuber- 
culosis. Clinical  observations  show  about  30  per  cent  of  frank 
involvement,  while  painstaking  examination  raises  this  percent- 
age to  forty  or  forty-five.  Besold  and  Gideonson  report  498  or 
26.73  per  cent  in  a  material  of  2,018  cases.  The  writer  reported 
61  cases  or  29.3  per  cent  of  well  marked  clinical  tuberculosis 
of  the  larynx  in  a  material  of  208  patients. 

Tuberculous  foci  in  the  larynx  are  accompanied  by  collateral 
inflammations  of  variable  severity.  Sometimes  this  amounts  to 
only  a  hyperemia;  at  other  times  there  is  a  marked  edema; 
and,  still  again  it  shows  as  a  purulent  exudate  with  destruction 
of  tissue. 

Laryngeal  lesions  of  the  proliferative  type  show  a  marked 
tendency  to  heal  when  properly  treated,  especially  in  cases 
where  the  pulmonary  disease  is  not  too  active.  Ulceration,  on 
the  other  hand,  while  often  healing,  shows  a  tendency  to  pro- 
gress. 

Tuberculous  Pleurisy. — Tuberculous  inflammation  of  the 
pleura  exists  both  as  tuberculous  foci  and  as  collateral  inflam- 
mation. Tuberculous  pleurisy  is  usually  spoken  of  as  being  of 
two  kinds,  the  exudative  and  the  dry,  although  this  is  not  strict- 
ly correct  from  the  pathological  standpoint,  for  even  the  dry 
is  due  to  a  fibrinous  exudate.  The  pleura  may  be  the  seat  of 
miliary  tuberculosis. 

Tuberculous  pleurisy  then,  is  an  exudative  inflammation  whieh 
may  be  serous,  sero-fibrinous,  fibrinous,  hemorrhagic,  or  puru- 
lent, in  character.  The  exudate  is  poured  out  into  the  pleural 
sac  either  as  a  result  of  a  tuberculous  process  affecting  the 
pleura  itself  or  the  subpleural  tissue  of  the  lung.  It  may  con- 
sist of  a  few  drops  of  fluid  or  of  an  exudation  sufficiently  large 
to  fill  the  pleural  space.  It  may  affect  one  side  or  both.  If  of 
the  fibrinous  character,  it  may  result  in  the  formation  of  a 
few  tender  fibrils  of  tissue  or  the  development  of  connective 
tissue  covering  the  entire  lung  surface  even  to  the  thickness  of 
an  inch. 

Purulent  exudation  infected  by  pus  organisms  is  rare  in  tu- 
berculosis, even  in  those  cases  of  spontaneous  pneumothorax 
where  a  necrotic  tubercle  breaks  through  into  the  pleural  cav- 
ity.    This  fact  goes  to  substantiate  the    theory    that    necrotic 


TUBERCULOUS  PLEURITIS  AND   PERICARDITIS  49 

processes  in  tuberculosis  are  not  as  a  rule  infected  by  or  due 
to  pus  organisms.  When  infection  occurs  it  is  probable  that 
an  old  infected  cavity,  rather  than  a  recent  necrotic  process 
breaks  into  the  pleura.  We  may  have  a  purulent  exudate  that 
is  not  infected,  due  to  cheesy  subplural  masses  breaking  into 
the  pleural  cavity.  This  is  considered  as  always  being  of  tuber- 
culous origin. 

Absorption  of  either  serous,  sero-fibrinous,  or  fibrinous  ex- 
udate may  take  place.  The  subpleural  lymphatics  have  great 
power  of  absorption;  but  if  the  amount  of  exudation  is  large  it 
compresses  the  lymphatics.  If  it  is  fibrinous  and  covers  much 
of  the  pleural  surface  it  closes  up  the  stomata  and  so  interferes 
with  absorption.  Absorption  of  fluid  is  often  hastened  by  the 
withdrawal  of  a  comparatively  small  amount  of  fluid.  It  is 
probable  that  this  acts  by  relieving  the  compression  of  the 
lymphatics,  thus  permitting  them  to  resume  their  function. 
Fibrinous  pleurisy  can  also  be  absorbed,  although  it  usually 
leads  to  adhesions  between  the  visceral  and  thoracic  pleurae. 

Often  following  pleurisy  a  large  amount  of  fibrous  tissue  is 
formed,  not  only  on  the  pleural  surface  but  extending  into  the 
lung  substance,  which  contracts  and  causes  much  deformity 
of  the  lung.  When  the  process  involves  the  diaphragmatic 
pleura,  the  action  of  this  important  muscle  of  respiration  is 
interfered  with  causing  a  chain  of  clinical  symptoms  (see  Vol. 
II,  Chap.  XXV) .  Often  the  pericardium  partakes  of  this  inflamma- 
tion resulting  in  an  embarrassment  of  the  heart.  The  motility 
of  the  affected  lung  is  decreased,  a  compensatory  emphysema 
results,  and  a  degree  of  strain  is  thrown  back  upon  the  heart. 

Tuberculous  Pericarditis. — Tuberculous  inflammation  of  the 
pericardium  may  result  from  tubercles  in  the  pericardium  it- 
self or  from  a  collateral  inflammation,  resulting  from  a  tuber- 
culous process  near  the  pericardium,  when  there  is  no  specific 
process  in  the  sac  itself.  It  may  be  an  extension  from  the 
pleura. 

The  process  m,ay  show  the  same  characteristics  as  pleurisy, 
the  exudate  being  serous,  sero-fibrinous,  cellular,  or  purulent. 
Purulent  pericarditis  is  extremely  rare. 

At  times  the  pericardium  takes  upon  itself  very  severe 
changes.     It  may  become  thickened,  the  cardiac  portion  some- 


50  PATHOLOGICAL   CHANGES   IN   TUBERCULOSIS 

times  appears  spongy.  The  two  surfaces  occasionally  become 
adherent  and  obliterate  the  entire  sac.  This  condition  is  fol- 
lowed by  myocarditis  and  atrophy  of  the  heart  muscle. 

When  the  exudate  is  serous  in  character  it  may  become  ab- 
sorbed of  its  own  account  the  same  as  pleuritis. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis  shows  all 
the  characteristics  of  tuberculosis  of  serous  membranes. 

Miliary  tuberculosis  is  a  very  common  variety  and  at  times 
is  found  unexpectedly  when  operating  in  the  abdominal  cavity. 
At  times  the  entire  peritoneum  is  studied  with  tubercles,  all 
apparently  of  the  same  age,  showing  that  they  are  of  common 
origin.  Their  distribution  and  characteristics  are  such  that 
they  can  only  be  of  hematogenous  origin.  This  form  shows  little 
or  no  tendency  to  necrosis  and  is  usually  not  accompanied  by 
exudation  unless  one  of  a  slightly  fibrinous  character.  Hyper- 
emia usually  surrounds  the  tubercles.  Being  of  hematogenous 
origin  and  of  low  virulence,  there  is  almost  no  collateral  inflam- 
mation. This  form  corresponds  to  the  disseminated  fibroid 
tuberculosis  of  the  lung  both  in  origin  and  virulence. 

Another  form  is  that  accompanied  by  serous  exudate.  This 
has  been  looked  upon  as  a  favorable  form,  especially  after 
operation,  since  Konigs'  report  in  1884.  It  is  also  favorable 
without  operation,  the  same  as  serous  pleuritis.  Many  reasons 
have  been  assigned  for  the  cure  of  peritoneal  tuberculosis  which 
takes  place  following  operation.  Some  have  explained  it  as 
being  due  to  the  light  entering  the  abdomen,  but  such  does  not 
seem  to  be  rational.  Others  have  thought  the  handling  of  the 
intestines  causes  a  hyperemia  which  favors  healing.  It  seems 
that  the  change  in  intra-abdominal  pressure  is  also  probably  a 
factor.  Anything  causing  increased  hyperemia  and  increased 
lymph  flow  is  valuable.  But  in  finding  a  reason  for  cure  fol- 
lowing operation  we  must  not  forget  that  cure  follows  without 
operation  in  probably  as  large  a  percentage  of  cases  as  it  does 
after  operation. 

This  form  of  tuberculosis  shows  nodules  of  various  sizes,  some 
of  which  are  often  necrotic.  There  may  be  considerable  forma- 
tion of  new  tissue  with  adhesions  and  a  matting  together  of  the 
intestines.  All  of  the  abdominal  organs  are  subject  to  dis- 
turbed function  and  sometimes  to  tuberculous  infection  as  a 


TUBERCULOUS  PERITONITIS  AND  ENTERITIS  51 

result  of  the  peritoneal  changes  or  as  a  part  of  the  same 
infection.  The  peritoneum  is  subject  to  all  the  different  forms 
of  exudation  that  other  serous  membranes  are,  serous,  fibrinous, 
sero-fibrinous,  cellular,   and  purulent. 

When  purulent  peritonitis  is  present,  the  fluid  may  rupture 
into  the  intestines  or  break  through  the  abdominal  wall.  When 
this  happens  it  usually  occurs  in  the  region  of  the  umbilicus. 
This  occurs  most  commonly  in  children. 

Not  only  serous  but  fibrinous  exudate  may  disappear.  Even 
adhesions  may  be  absorbed,  leaving  no  trace.  This  is  analogous 
to  what  happens  in  the  absorption  of  adhesions  after  ordinary 
operations  in  the  abdomen. 

Tuberculous  Enteritis. — Tuberculosis  of  the  intestinal  tract 
is  a  very  common  complication  of  advanced  pulmonary  tuber- 
culosis. The  process  may  cause  distressing  symptoms  or  it  may 
be  present  without  being  suspected  during  life.  The  most  fre- 
quent seat  of  tuberculous  infection  is  in  the  lower  ileum,  cecum, 
appendix,  and  ascending  colon,  although  any  portion  of  the  gut 
may  be  involved.  Even  the  stomach  shows  tubercles  occa- 
sionally. It  is  interesting  to  note  that  the  most  common  seats 
of  infection  are  the  areas  favored  by  stasis  of  the  contents  of 
the  bowels,  thus  favoring  the  theory  of  contact  infection.  The 
mucous  membrane  of  the  lower  portion  of  the  large  bowel  is  at 
times  the  seat  of  ulceration,  at  other  times  it  is  involved  in  a 
fistulous  process  from  a  tuberculous  abscess  in  the  deep  tissues 
around  the  rectum.  The  process  which  leads  to  the  formation 
of  a  pulmonary  cavity  and  that  which  leads  to  the  formation 
of  a  rectal  fistula  is  the  same  except  that  it  affects  different 
tissues. 

The  tuberculous  process  in  the  intestines  may  belong  either 
to  the  proliferative  or  degenerative  type,  or  may  be  a  mixture 
of  the  two.  Ulceration  is  a  common  form  of  the  infection  and 
is,  occasionally,  the  cause  of  perforation.  At  times,  however, 
there  is  a  tendency  to  the  generation  of  new  tissue  and  we  find 
the  walls  of  the  intestines  enormously  thickened.  At  times  the 
gut  appears  like  a  thick-walled  tube.  Again,  there  is  a  local 
thickening  with  constriction  at  intervals  along  the  course  of 
the  gut;  the  portions  between,  becoming  thin  and  greatly  dilated 
because  of  the  distention  that  takes  place  as  a  result  of  the 


52  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

bowel  contents  and  gas  collecting  between  the  obstructions.  The 
thickenings  of  the  gut  sometimes  cause  stricture  of  the  lumen. 

It  was  formerly  thought  that  bacilli  in  the  feces  were  diag- 
nostic of  tuberculous  enteritis,  but  we  now  know  that  a  pro- 
liferative process  might  be  present  without  discharging  bacilli 
in  the  bowel.  Three  hundred  examinations  of  stools  made  in 
the  laboratory  of  the  Pottenger  Sanatorium  showed  tubercle 
bacilli  present  in  the  stools  in  about  one-half  of  the  cases  of  ad- 
vanced tuberculosis,  when  the  greatest  care  was  taken  to  avoid 
the  swallowing  of  sputum.  Preparatory  to  the  test,  the  pa- 
tient was  especially  instructed  not  to  swallow  any  sputum. 
Then  a  dose  of  castor  oil  was  given.  After  the  effects  of  the  oil 
had  passed,  the  stool  was  saved  for  examination.  The  stool 
was  homogenized  by  shaking  in  the  shaking  machine  and  a 
smear  was  taken  for  examination.     (See  Chapter  XX.) 

Tuberculous  enteritis  of  the  ulcerative  type  shows  very  little 
tendency  to  heal  although  we  do  sometimes  find  evidence  of  its 
having  occurred.  These  ulcers  sometimes  perforate  allowing 
the  bowel  contents  to  escape  into  the  peritoneum. 

Diarrhea  is  not  a  necessary  accompaniment  of  ulceration  of 
the  bowel.  This  depends  much  on  the  location  of  the  lesion. 
Some  of  the  most  extensive  ulcerations  in  the  region  of  the 
cecum  that  I  have  seen,  postmortem,  were  accompanied  by  a 
normal  stool,  others  by  a  soft  stool,  and  still  others  by  constipa- 
tion. When  the  lower  end  of  the  large  bowel  is  the  seat  of  ul- 
ceration severe  diarrhea  is  apt  to  be  present. 

The  question  of  primary  infection  of  the  bowel  has  received 
careful  attention  since  Koch's14  announcement  of  the  view  that 
human  and  bovine  bacilli  differ.  Out  of  the  great  mass  of  experi- 
mental study  the  conclusion  has  finally  been  drawn  that  bovine 
bacilli  are  a  menace  to  human  beings  and  accountable  for  a  con- 
siderable amount  of  tuberculosis  among  children,  particularly 
the  non-pulmonary  forms.  (See  Chapter  II  for  further  discus- 
sion of  this  point.)  In  order  to  produce  infection  through  the 
alimentary  canal  it  is  not  necessary  that  the  bacilli  should  pro- 
duce a  primary  lesion  in  the  intestinal  wall.  The  bacilli  when 
first  taken  in,  pass  through  the  walls  of  the  gut  and  are  carried 
by  the  lymph  to  the  glands  of  the  mesentery  and  even  to  the 

"Report  of  the  International   Congress  on  Tuberculosis,   London,    1901. 


TUBERCULOUS  ENTERITIS  53 

mediastinum;  or  may  be  carried  by  the  lacteals  to  the  thoracic 
duct  and  emptied  directly  into  the  blood  stream  to  be  strained 
out  in  any  organ. 

The  difference  in  the  action  of  the  intestinal  wall  toward 
bacilli  taken  in  in  early  life  and  those  swallowed  with  tuber- 
culous sputum  requires  some  consideration  although  I  have 
never  seen  this  question  discussed.  Why  do  the  bacilli  pass 
through  the  intestinal  wall  of  children,  or  we  might  say,  of 
the  non-tuberculous  in  general  and  leave  no  trace,  while  they 
produce  infiltrations  and  ulceration  in  the  walls  of  the  intestines 
of  those  suffering  from  tuberculosis?  Is  the  difference  in  be- 
havior due  partly  or  wholly  to  the  great  numbers  of  bacilli 
swallowed  by  the  sufferer  from  advanced  pulmonary  tubercu- 
losis in  comparison  with  the  few  which  enter  the  intestinal 
tract  of  the  non-tuberculous?  Is  it  not  probable  that  the  differ- 
ence is  due  more  to  the  sensitization  of  the  cells  in  the  intestinal 
wall  in  the  one  as  compared  with  the  lack  of  it  in  the  other? 
Is  it  not  probable  that  it  is  the  same  experiment  as  that  of  Koch 
which  showed  the  difference  between  the  inoculation  of  the 
tuberculous  and  the  healthy  guinea  pig?  Prior  to  the  time  that 
infection  has  occurred  and  the  cells  have  been  endowed  with 
specific  defensive  powers  (sensitized)  the  bacilli  pass  through 
the  mucous  membranes  with  little  opposition  and  are  carried 
to  the  regional  lymph  glands;  but,  after  infection  has  taken 
place,  the  bacilli  which  enter  the  tissues  of  the  gut  set  up  a  re- 
action with  the  local  cells  which  results  in  an  inflammation;  an 
infiltration  resulting  if  the  bacilli  are  of  low  virulence,  and  an 
ulceration  if  they  are  of  a  more  virulent  strain.  This  cell  sen- 
sitization is  probably  a  factor  in  all  metastases  and  superinfec- 
tions, such  as  those  in  the  lung  and  larynx.  This  subject  will 
need  much  careful  study  for  it  will  probably  explain  many  of 
the  vagaries  noted  in  extensions  of  the  tuberculous  process.  (See 
Chapter  III  for  a  more  complete  discussion.) 

Tuberculosis  of  the  Liver. — The  liver  may  be  the  seat  of  mili- 
ary tubercles,  or  it  may  contain  cheesy  degenerated  foci,  or 
may  show  a  general  fibrosis  (tuberculous  cirrhosis).  It  may  be 
infected  through  the  alimentary  canal  or  through  the  blood 
from  a  focus  in  the  lung  or  other  parts  of  the  body.    Some  ob- 


54  PATHOLOGICAL   CHANGES   IN   TUBERCULOSIS 

servers  report  finding  tubercles  in  nearly  90  per  cent  of  livers 
of  those  dying  of  chronic  tuberculosis. 

Aside  from  the  specific  tuberculous  infection,  the  liver  is  the 
seat  of  non-tuberculous  degeneration  in  chronic  tuberculosis. 
Its  cells  show  cloudy  swelling  of  various  degrees  and  fatty  de- 
generation is  extremely  common.  "When  fatty  degeneration  is 
present  miliary  tuberculosis  may  be  present  and  be  overlooked. 

A  perihepatitis  is  often  present  especially  involving  the  dia- 
phragmatic portion  of  the  liver.  This  results  as  an  extension 
of  an  inflammation  from  the  diaphragmatic  pleura. 

Tuberculosis  of  the  Spleen. — Tuberculosis  of  the  spleen  is 
sometimes  of  hematogenous  origin  and  takes  the  form  of  miliary 
tuberculosis ;  again,  it  may  be  of  lymphogenous  origin  in  which  case 
the  foci  are  apt  to  be  of  variable  size  and  may  be  necrotic. 
When  of  lymphogenous  origin  the  bacilli  are  implanted  in  the  peri- 
vascular lymph  spaces,  while  the  hematogenous  type  is  found 
in  the  pulp  of  the  organ. 

Tuberculosis  of  the  Glands. — We  recognize  the  spreading  of 
tuberculosis  through  the  lymph  channels  in  connection  with  the 
pathology  of  all  the  organs  of  the  body.  We  see,  too,  that  it  is 
a  form  of  spreading  which  favors  a  virulent  metastasis  because 
the  bacilli  escape  from  the  tubercle  into  adjacent  tissue  which 
has  been  injured  by  toxins  in  which  the  lymph  movement  is 
slow ;  and  the  bacilli  may  be  thrown  into  the  lymph  spaces  in  num- 
bers and  find  themselves  surrounded  by  conditions  favorable  for 
growth.  An  exception  to  this  is  found  near  the  hilus  where  bacilli 
gain  entrance  to  the  large  lymphatic  trunks  and  produce  infec- 
tion with  difficulty;  the  type,  as  a  rule,  being  abortive  in  charac- 
ter. The  condition  as  a  rule,  however,  is  the  opposite  of  that 
which  obtains  when  bacilli  enter  the  blood  stream.  Here  the 
rapidly  flowing  blood  scatters  the  bacilli  to  different  parts  of 
the  body  and  prevents  their  heaping  up  in  any  one  focus.  They 
are  injured  by  the  antibacillary  elements  of  the  blood  and  be- 
come implanted  in  healthy  tissue  which  possesses  specific  cellu- 
lar defense.  The  result  is  that  tuberculosis,  spread  by  the  lym- 
phatics, is  an  implantation  of  numbers  of  bacilli  in  each  focus,  fol- 
lowed by  rapid  multiplication  and  necrosis,  while  that  spread  by 
the  way  of  the  blood,  unless  enormous  numbers  of  bacilli  gain  en- 
trance to  the  blood  stream,  is  an  implantation  of  isolated  or 


i  TUBERCULOSIS   OF  LYMPHATIC   STRUCTURES  55 

few  bacilli  in  the  capillaries  of  an  area  of  greater  or  lesser  ex- 
tent, followed  by  a  slow  multiplication  which  favors  stimula- 
tion of  the  cells  to  the  formation  of  new  tissue.  Tuberculosis 
which  spreads  by  the  lymphatics  then,  is,  for  the  most  part,  ac- 
companied by  necrosis,  more  or  less  toxemia,  considerable  col- 
lateral inflammation,  and  has  a  tendency  to  rapid  destruction  of 
tissue;  while  that  which  spreads  by  the  blood  stream  is  com- 
paratively mild,  non-virulent,  accompanied  by  slight  toxemia 
and  shows  a  tendency  to  produce  new  tissue  and  either  becomes 
encapsulated  or  runs  a  chronic  course.  The  exceptions  to  this 
are  acute  miliary  tuberculosis  of  hematogenous  origin  where  the 
inoculation  is  so  massive  that  it  destroys  the  patient;  and  that 
non-virulent  infection  of  the  lungs  which  takes  place  through 
the  large  lymph  trunks  near  the  hilus. 

Aside  from  the  part  that  the  lymphatics  play  in  the  dis- 
semination of  bacilli  through  the  body,  the  walls  of  the 
lymphatics  themselves,  and  particularly  the  glands,i  may  be 
infected  by  tuberculosis.  Occasionally,  a  miliary  tuberculosis 
results  from  a  rupture  of  a  tubercle  in  the  walls  of  the  thoracic 
duct. 

Tuberculosis  is  primarily  a  lymphatic  disease.  No  matter  in 
what  manner  bacilli  gain  entrance  to  the  body,  they  find  their 
way  to  the  lymphatics  and  usually  to  the  neighboring  lymph 
glands,  there  to  set  up  the  disease.  (See  page  84.)  It  is  from 
this  focus  of  infection  that  the  disease  spreads  to  other  tissues 
either  adjacent  or  distant.  While  tuberculosis  of  the  lymph 
glands  is,  in  itself,  not  so  serious;  yet  when  we  consider  that  it 
is  the  cause  of  the  metastases  in  other  parts  of  the  body,  it  as- 
sumes great  importance. 

Tuberculosis  of  the  lymph  glands  is  a  very  different  patho- 
logical lesion  from  tuberculosis  which  spreads  in  the  tissues  ad- 
jacent to  other  tubercles  by  way  of  the  lymph  spaces.  The 
former  is  usually  a  non-virulent  infection,  the  latter  a  virulent 
one.  The  difference  is  that  the  former  focus  is  one  constantly 
bathed  with  fresh  lymph,  consequently  the  bacilli  are  kept  of 
low  virulence,  while  the  focus  which  spreads  by  a  heaping  up  of 
bacilli  in  lymph  spaces  is  surrounded  by  stagnated  lymph  and 
the  bacilli  are  left  to  multiply  rapidly,  producing  a  virulent 
process. 


56  PATHOLOGICAL   CHANGES  IN   TUBERCULOSIS 

The  glands  commonly  infected  are  the  cervical  which  drain 
the  nasopharynx,  gums  and  tonsils;  the  mesenteric;  and,  most 
commonly,  the  peribronchial.  Figs.  13  and  14,  pages  93  and  94, 
show  the  relationship  of  the  structures  in  the  pharynx  and  oro- 
pharynx to  the  deep  cervical  lymphatic  glands. 

The  glands  are  sometimes  enormously  enlarged.  They  may 
present  any  degree  of  inflammation,  sometimes  being  almost 
free  from  accompanying  symptoms,  and,  again,  showing  signs 
of  acute  inflammation.  Sometimes  the  center  becomes  necrotic, 
and  breaks  down,  discharging  its  contents  either  externally  or 
into  the  adjoining  tissues.  Rupture  into  a  vein  or  the  thoracic 
duct  may  cause  general  miliary  tuberculosis. 

After  the  glands  have  become  necrotic,  lime  salts  may  be  de- 
posited forming,  in  the  lung,  the  "lung  stones"  which  patients 
sometimes  expel. 

Inflamed  glands  may  not  go  on  to  caseation,  but  become 
fibroid  in  character.  Such  glands  usually  lose  their  function- 
ating power  the  same  as  the  necrotic  and  calcareous  ones. 


CHAPTER  II. 

THE  SOURCE  AND  ROUTES  OF  INFECTION  AND  THE 
PRIMARY  FOCUS. 

In  discussing  the  theme  of  infection  we  enter  upon  the  con- 
sideration of  questions  which  have  received  the  attention  of 
many  able  investigators  but  still  remain  in  doubt. 

Source  of  Infection. — Until  Koch  made  his  announcement  at 
the  British  Congress  on  Tuberculosis  in  1901,  the  identity  of 
the  bovine  and  human  bacillus  had  been  questioned  among  men 
of  scientific  reputation  only  by  Theobald  Smith;  and  their  inter- 
transmissibility  was  generally  accepted.  Not  only  was  the  in- 
tertransmissibility  of  these  two  types  of  bacilli  considered  as  a 
fact,  but  they  were  looked  upon  as'  being  of  almost  equal  etio- 
logical importance  in  the  production  of  clinical  tuberculosis. 
After  this  announcement,  however,  many  workers  in  all  lands 
spent  years  in  earnest  investigation  of  this  subject,  finally  ar- 
riving at  certain  conclusions  which  seem  to  satisfy  the  scientific 
world  at  large.  Koch's  theory,  as  he  first  announced  it,  con- 
firming that  of  Theobald  Smith,  that  there  is  a  difference  be- 
tween bovine  and  human  tubercle  bacilli,  is  now  generally  ac- 
cepted; but  Koch's  further  statement  that  bovine  bacilli  are  of 
little  or  no  consequence  in  the  causation  of  human  tuberculosis, 
has  not  been  substantiated.  The  conclusion  has  been  reached, 
however,  that  the  human  bacillus  is  the  main  source  of  human 
tuberculosis  and  that  the  bovine  bacillus  is  accountable  for  a 
much  smaller  proportion  of  the  disease  than  we  formerly  be- 
lieved. While  it  is  difficult  to  say  how  much  tuberculosis  is  of 
bovine  origin  and  how  much  of  human  origin,  yet  pathologists 
who  have  studied  the  question  carefully  now  agree  that  about 
eleven-twelfths  of  all  tuberculosis  in  man  is  caused  by  human 
bacilli  and  about  one-twelfth  by  bovine  bacilli;  and  that  bovine 
infection,  as  it  occurs,  predominates  in  childhood,  while  the  hu- 
man infection,  although  accountable  for  a  large  per  cent  of  dis- 


58 


SOURCE  AND  ROUTES   OP  INFECTION 


ease  during  childhood  is  accountable  for  nearly  all  disease  of 
adult  life. 

Park  and  Krumwiede1  analyzed  1,038  cases  of  tuberculosis, 
which  had  been  carefully  studied,  with  the  following  results: 


Age  Period 

Per  Cent  of 
Human  Tuberculosis 

Per  Cent  of 
Bovine  Tuberculosis 

6 — 1 1  years 

16  years  and  over 

73.5 

75. 

98.69 

26.5 
25. 
1.31 

In  this  connection  the  following  table  from  the  Imperial  Ger- 
man Board  of  Health  is  also  interesting.  It  presents  an  analysis 
of  1,400  investigated  cases. 


Total 
Number 
Investi- 
gated 

Cases 

Types 

PerCentof  All  Cases 
Due  to  Bovine  Type 

Human 

Bovine 

In 

Adults 

In 

Chil- 
dren 

Tuberculosis  of  the  lungs. . . 
Tuberculosis   of  the   bones 

811 

99 

33 

178 

167 

112 

807 

95 

30 

147 

120 

78 

5 

5 

3 

33 

47 

35 

0.66 

6.66 

0. 

2.5 

5.8 

12.0 

0. 
4.3 

Meningeal  tuberculosis.  . .  . 

Generalized  tuberculosis. .  . 

Tuberculosis  of  the  cervical 

glands 

10.34 
23.18 

40.7 

Tuberculosis  of  the  mesen- 

51.0 

Totals 

1400 

1277 

128 

The  studies  of  Eastwood  and  Griffith2  are  very  interesting  in 
that  they  have  made  a  special  study  of  the  type  of  infection 
in  bone  and  joint  tuberculosis.  Basing  their  classification  upon 
cultural  characteristics  and  the  virulence  of  the  bacilli  as  shown 
upon  rabbits,  they  examined  a  total  of  261  cases  and  found  the 
human  type  of  bacilli  in  196,  bovine  in  55,  and  a  bacillus  which 
they  were  unable  to  classify,  in  10. 

I  desire  to  emphasize  in  this  connection  the  fact  that  the 
bovine  type  of  bacillus  disappears  very  rapidly  from  clinical 


iThe  Relative  Importance  of  the  Bovine  and  Human  Types  of  Tubercle  Bacilli  in 
the  Different  Forms  of  Tuberculosis,  Journal  of  Medical  Research,  December,  1911. 

2The  Characteristics  of  Tubercle  Bacilli  in  Human  Bone  and  Joint  Tuberculosis, 
Journal  of  Hygiene,  vol.  xv,  No.  2,  1916. 


BOVINE  AND   HUMAN  INFECTION 


59 


tuberculosis  after  the  tenth  year,  indicating,  as  I  have  ex- 
pressed elsewhere,  that  the  bovine  bacillus  produces  infection 
only  during  early  child  life;  or,  that  it  probably  changes  its 
characteristics  with  growth  upon  human  soil  for  many  years,  and 
assumes  the  characteristics  of  the  human  bacillus.3 

The  results  of  the  examinations  reported    by    Eastwood    and 
Griffith  are  shown  in  the  following  tables: 


Types  of  Tubercle  Bacillus  at  Different  Age  Periods 


AGE  PERIOD 

NUMBER    OF    CASES 

HUMAN 

BOVINE 

ATYPICAL 

16 — 25  years 

Over  25  years 

47 
108 
62 
15 
29 

31 
75 
52 
12 
26 

14 

31 

7 
3 

2 
2 
3 

3 

Total 

261 

196 

55 

10 

The  percentage  of  "bovine"  cases  are: 

All  ages  (55  out  of  261) 21.1  per  cent 

Under   10  years    (45  out  of  155)... 29.0  per  cent 

Over    10    years      (10  out  of  106) 9.4  per  cent 

We  must  recognize  the  fact  that  our  methods  of  determining 
the  difference  between  bovine  and  human  infection  are  not  abso- 
lutely reliable ;  yet  we  cannot  help  noting  that  the  results  obtained 
by  different  observers  agree  fairly  well.  It  is  also  suggestive  that 
all  find  little  bovine  infection  in  adult  life. 

These  same  writers  have  made  a  study  of  the  types  of  bacilli 
occurring  in  the  genitourinary  tract  and  I  will  quote  their  sum- 
mary. 

"Seventeen  cases  were  examined,  the  disease  affecting  the 
genital  organs  in  nine  instances  (seven  testicles,  one  salpinx,  one 
prostate)  and  the  urinary  tract  in  eight. 

"The  bacilli  obtained  were  of  'human'  type  in  fourteen  cases 
and  'bovine'  in  three. 

"The  three  'bovine'  cases  were  affections  of  the  kidney  in 
persons  aged,  respectively,  25,  19  and  20  years." 

Griffith*  further  reports  an  analysis  of   results    obtained    from 


8Pottenger:  The  Relation  of  Bovine  Infection  in  the  Child  to  Clinical  Tuberculosis 
in    the    Adult,    Southern    Medical    Journal,    November,    1915. 

investigations  of  Strains  of  Tubercle  Bacilli  Derived  from  Sputum,  The  Lancet, 
London,  No.   4,831,  vol.   cxc,  April    1,    1916. 


60 


SOURCE  AND  ROUTES  OF  INFECTION 


the  investigation  of  sputum  of  212  patients  suffering  from  pul- 
monary tuberculosis,  with  the  following  results: 


Number  of  Cases 

Type  of  Tubercle  Bacilli 
Isolated 

STANDARD 
HUMAN 

ATYPICAL 
HUMAN 

STANDARD 
BOVINE 

England 

139 

73 

135 

70 

2 
2 

2 
1 

Total 

212 

205 

4 

3 

In  discussing  this  question  Griffith  says: 

"In  this  country,  therefore,  pulmonary  tuberculosis  which, 
has  arrived  at  the  ulcerative  stage  is  but  very  rarely  referable 
to  tubercle  bacilli  of  bovine  type.  And  elsewhere  than  in  Britain 
an  even  smaller  proportion  of  the  sputa  of  persons  suffering 
from  pulmonary  tuberculosis  has  yielded  bacilli  of  bovine  type. 
Out  of  736  cases  tested  by  foreign  investigators  3  only  yielded 
bovine  tubercle  bacilli;  and  further,  in  2  of  these  3  the  bovine 
bacillus  was  only  sparsely  mixed  with  preponderating  bacilli  of 
human  type,  while  in  the  third  case  proof  was  not  afforded  (only 
a  single  examination  of  the  sputum  having  been  made)  that  in 
this  instance  also  both  types  of  tubercle  bacillus  were  not  co- 
existent in  the  lungs  of  the  patient." 

While  such  apportionment  of  the  bovine  and  human  infec- 
tion in  man  seems  to  be  fairly  well  accepted,  yet  it  comes  in  con- 
flict with  other  pathological  ideas  which  seem  to  be  fairly  estab- 
lished. We  are  taught  today  that  clinical  tuberculosis  in  adult 
life  is  largely  an  extension  from  an  infection  which  takes  place 
in  early  child  life  (Romer).  If  this  is  true,  and  our  knowledge 
of  the  disease  supports  the  theory,  what  is  there  to  hinder  this 
metastatic  infection  in  later  life  from  being  of  either  bovine 
or  human  origin;  and,  according  to  the  data  quoted  above,  why 
is  not  adult  tuberculosis  more  largely  of  bovine  type,  unless  mu- 
tation of  type  takes  place?  Children  unquestionably  take  in 
both  types  of  bacilli  and  are  infected  by  the  same;  and,  as  yet 
we  do  not  know  that  the  resulting  infections  differ  to  any  great 
extent,  or  even  at  all,  in  their  subsequent  pathological  changes 
or  clinical  course. 


BOVINE  AND  HUMAN  INFECTION  61 

Bovine  Infection  Cannot  be  Differentiated  From  Human  In- 
fection Either  by  Localization  or  Character  of  the  Lesion. — 

Many  observers,  among  whom  is  the  writer,  have  been  inclined 
to  believe  that  those  forms  of  tuberculosis  which  seem  to  pre- 
dominate in  organs  other  than  the  lungs,  and  which  are  partic- 
ularly common  in  early  childhood,  are  most  probably  due  to 
bovine  infection.  We  were  inclined  to  believe  that  the  typical 
human  infection  is  tuberculosis  of  the  lungs;  and  to  look  upon 
other  forms  of  tuberculosis,  such  as  those  involving  the  bones, 
joints,  glands,  meninges,  intestinal  tract  and  peritoneum  as 
being  atypical ;  and,  since  these  forms  are  more  common  in  child- 
hood than  in  adult  life,  to  consider  them  as  belonging  to  the 
bovine  type  of  the  disease.  Believing  that  the  bovine  bacillus 
is  less  virulent  for  man  than  the  human  type,  we  reasoned  that 
it  would  probably  produce  an  atypical  disease.  Further  study, 
however,  seems  to  make  this  untenable. 

As  near  as  we  know  at  the  present  time,  tubercle  bacilli, 
whether  of  human  or  bovine  type,  no  matter  how  they  are  taken 
into  the  body,  whether  it  be  through  the  upper  or  lower  respira- 
tory tract,  through  the  tonsils,  pharyngeal  mucous  membranes, 
or  intestinal  tract,  find  their  way  into  the  lymph  spaces,  and, 
for  the  most  part,  into  the  lymphatic  glands  and  establish  a 
primary  lymphatic  tuberculosis.  As  exceptions  to  this,  are 
such  cases  of  tuberculosis  as  are  produced  by  the  direct  in- 
halation of  bacilli  into  the  finer  air  passages  (if  such  occurs), 
setting  up  a  local  infection  in  the  pulmonary  tissues  at  the  point 
of  inoculation;  and,  infections  produced  by  bacilli  passing 
through  the  intestinal  mucous  membranes  and  being  taken  up 
by  the  lacteals  and  poured  into  the  thoracic  duct  from  which 
they  are  emptied  into  the  blood  stream  and  carried  directly 
to  the  capillaries  of  the  lung,  or  other  organs  where  they  find 
lodgment  and  produce  infection.  The  bacilli  which  would  take 
either  of  these  latter  courses  might  be  either  of  the  bovine  or 
human  type.  They  could  be  taken  in  either  by  inhalation  or 
ingestion,  and  their  implantation  could  occur  wherever  the  blood 
stream  is  sufficiently  retarded  for  the  bacilli  to  find  time  to  en- 
ter the  tissues.  It  is  in  this  manner  that  we  recognize  the  pos- 
sibility of  primary  infection  of  organs  other  than  the  lymphatic 
glands  taking  place. 


62  SOURCE  AND  ROUTES  OF  INFECTION 

In  the  primary  lymphatic  tuberculosis,  as  far  as  we  know, 
there  is  no  clinical  method  of  distinguishing  tuberculosis  of  the 
bovine  type  from  tuberculosis  of  the  human  type.  This  is  left 
to  laboratory  investigation  and  animal  experimentation.  "We 
know  that  both  bovine  and  human  bacilli  can  affect  these  glands 
alike,  and  that  up  to  this  point  the  paths  of  infection  are  un- 
doubtedly the  same.  From  this  point  the  bacilli  are  carried  by 
the  lymph  stream ;  by  wandering  cells ;  or,  breaking  into  a  blood 
vessel,  are  transported  to  other  parts  of  the  body,  either  adja- 
cent or  remote.  Such  a  course  is  as  likely  to  be  followed  by 
bovine  bacilli  as  by  human  bacilli.  If  bacilli  gain  access  to  a 
vessel  which  leads  toward  the  heart  the  metastasis  from  the 
lymph  gland  would  most  probably  be  in  the  lung  because  the 
bacilli  would  most  likely  be  strained  out  by  the  capillaries  in 
the  lung.  If,  on  the  other  hand,  the  bacilli  should  not  be 
strained  out  in  the  lung  but  pass  on  through  the  left  heart ;  or, 
if  they  should  pass  directly  into  the  systemic  circulation  (as  by 
passing  into  the  pulmonary  veins),  they  might  be  strained  out 
in  any  part  of  the  body,  the  intestines,  liver,  kidney,  bones, 
joints,  meninges,  or  any  other  organ.  Where  this  implantation 
will  occur  depends  upon  where  the  blood  current  is  sufficiently 
retarded  to  permit  the  bacilli  to  become  implanted.  This  offers  a 
basis  for  primary  infection  of  many  organs. 

There  has  been  considerable  confusion  of  opinion  as  regards 
metastatic  tuberculosis.  While  it  is  probable  that  the  disease 
may  spread  from  the  primary  focus  by  way  of  either  the  lymph 
stream,  wandering  cells,  or  the  blood  stream,  it  is  equally  prob- 
able that  most  metastases  which  are  responsible  for  a  new  area 
of  infection  must  take  place  through  the  blood  stream.  In  the 
case  of  metastases  distant  from  the  primary  focus  in  such  or- 
gans as  the  kidney,  joints,  bones  and  meninges,  this  is  evident. 
In  the  lung,  some  writers  think  the  lymph  stream  and  wander- 
ing cells  are  the  important  factors,  while  others  think  the  bronchi 
are  most  important. 

Important  as  bearing  upon  this  is  the  theory  which  is  ac- 
cepted by  such  students  of  the  subject  as  Tendeloo,  that  bacilli 
may  be  transported  against  the  lymph  stream.  While  the  gen- 
eral course  of  the  lymph  stream  in  the  lung  is  toward  the  hilus 
glands,   with  the   alternate   contraction   and   expansion  of  the 


TYPE   OP  DISEASE   AND   INFECTION  63 

pulmonary  tissue,  it  is  quite  possible  for  the  lymph  to  be  forced 
backwards  in  its  course  and  carry  bacilli  with  it. 

It  is  not  improbable  that  those  infections  of  pulmonary  tissue 
which  take  place  around  and  extend  out  into  the  lung  from  the 
hilus,  might  be  implantations  which  have  taken  place  through 
the  lymph  stream.  At  this  point  the  lymphatic  trunks  are  larg- 
er, the  current  is  retarded  and  implantation  is  favored.  This  is 
the  tuberculosis  which  is  detected  by  the  x-ray  when  the  apex 
is  not  involved.  It  is  quite  different,  however,  from  the  usual 
clinical  tuberculosis  which  begins  at  the  apex,  whose  implanta- 
tion has  been  not  in  contiguous  tissue,  but  in  tissue  widely 
separated  from  the  primary  source  of  infection.  In  this  latter 
infection  the  blood  stream  alone  solves  the  problems  connected 
with  the  distant  implantation. 

While  we  have  been  inclined  to  look  upon  the  non-pulmonary 
forms  of  tuberculosis  as  being  different  from  tuberculosis  of  the 
lungs, — as  being  a  milder  infection, — and  to  suppose  that  bovine 
bacilli,  not  being  so  well  adapted  to  human  soil,  are  more  apt  to 
produce  a  milder  infection,  our  newer  knowledge  brings  this 
theory  into  question.  The  reason  we  look  upon  tuberculosis 
of  the  lungs  as  being  a  more  virulent  process  than  tuberculosis 
in  these  other  organs  is  partly,  at  least,  because  we  are  com- 
paring different  conditions.  The  infection  which  takes  place 
through  the  blood  in  nearly  all  instances,  whether  it  be  a  pri- 
mary or  a  metastatic  infection,  is  benign;  exceptions  being  in 
those  instances  where  a  large  number  of  bacilli  are  poured  into 
the  blood  stream  at  once  and  produce  a  widespread  miliary  tu- 
berculosis. This,  too,  would  be  benign  were  it  not  for  the  great 
numbers  of  bacilli,  causing  widespread  infection.  Only  the 
mass  of  the  infection  makes  it  serious. 

When  tubercle  bacilli  break  into  the  blood  stream  in  small 
numbers  they  are  so  diluted  and  so  acted  upon  by  the  protec- 
tive substances  found  in  the  circulating  blood  and  so  opposed 
by  the  defensive  properties  of  the  tissue  cells  in  which  they  at- 
tempt to  settle  that,  for  the  most  part,  they  are  destroyed.  In 
those  instances  where  they  succeed  in  producing  an  infection, 
this  infection  is  caused  by  such  bacilli  as  have  been  able  to 
escape  the  antibacillary  action  of  the  blood  elements ;  but  which, 
we  are  justified  in  suspecting,  have  been  reduced  in  virulence; 


64  SOURCE  AND  ROUTES   OF  INFECTION 

so  that  we  have  an  infection  caused  by  a  few  bacilli  and  those 
bacilli  of  moderate  virulence.  Most  of  these  infections  being 
metastases,  the  implantation  takes  place  in  tissues  whose  cells 
are  sensitized  and  able  to  put  up  a  specific  defense.  The  result 
is  that,  instead  of  a  rapid  multiplication  of  bacilli  with  necrosis 
and  caseation,  and  a  rapidly  developing  activity,  we  have  an 
infection  produced  by  an  organism  which  is  reduced  in  viru- 
lence and  barely  able  to  exist,  consequently  we  have  an  irrita- 
tion with  resultant  new  tissue  formation,  and  a  focus  fibroid  in 
character.  Thus  we  can  see  that  nearly  all  early  infections  are 
of  this  type.  Infection  in  such  organs  as  the  bones,  joints,  kid- 
neys, meninges  and  visible  glands,  is  usually  discovered  as  soon 
as  irritation  starts,  at  a  time  when  the  focus  is  small.  Tuber- 
culosis in  the  lung,  however,  is  not,  as  a  rule,  discovered  during 
this  early  stage.  The  small  focus  produces  either  no  recogniz- 
able symptoms  or  so  few  symptoms  that  its  presence  is  not 
suspected;  and  there  it  remains,  for  years  often,  before  it  be- 
comes a  clinical  entity. 

As  soon  as  the  bacilli  begin  to  multiply,  however,  toxins  escape 
into  the  adjacent  tissues,  a  collateral  inflammation  ensues  and 
the  whole  process  assumes  a  state  of  active  inflammation. 
Symptoms  now  appear  and  the  disease  is  recognizable.  If  it 
goes  on  to  a  wide  extension  into  adjacent  tissues,  as  it  often 
does,  we  have  an  advanced  process  and  one  that  is  not  easy  to 
heal.  This  is  the  picture  of  the  process  in  the  lung  which  is 
being  compared  with  the  small  focus  in  other  organs.  If  the 
bacilli  become  active,  multiply,  and  produce  necrosis  and  casea- 
tion in  other  organs,  then  we  have  marked  symptoms  on  their 
part,  the  same  as  on  the  part  of  the  lung. 

It  does  not  seem  then,  from  the  data  at  hand,  that  we  are 
justified  in  saying  that  there  is  a  difference  in  the  type  of  bacilli 
that  produce  the  disease  in  such  locations  as  bones,  joints, 
meninges  and  glands,  from  that  produced  in  the  lung.  It  is 
more  probable  that  we  are  comparing  slight  activity  in  a  small 
fibroid  lesion  in  one  instance  with  a  rapidly  extending  or  more 
marked  activity  in  the  other;  and  it  further  seems  that  when 
we  add  the  differences  in  the  character  of  the  tissue  and  the 
function  of  the  organs  involved  that  we  probably  have  a  satis- 
factory explanation  for  the  difference  in  the  character  of  the 


MUTATION   OF  TYPE  POSSIBLE  65 

disease  in  the  different  parts.  It  may  be  that  there  are  certain 
points  of  election,  that  there  is  a  certain  soil  that  is  particularly 
suitable  to  the  growth  of  the  bovine  bacillus  and  certain  tissues 
and  soil  that  are  more  suitable  to  the  human  bacillus,  but  of  this 
we  cannot  be  sure.  It  is  also  not  improbable  that  long  growth 
on  unsuitable  soil  is  followed  by  adaptive  changes  on  the  part  of 
the  bacillus. 

On  the  other  hand,  we  are  justified  in  assuming  that  the 
bovine  bacillus  can  be  taken  into  the  system  in  the  same  manner 
as  the  human  bacillus,  that  it  must  pass  through  the  same  bar- 
riers to  get  into  the  tissues,  and  that  it  probably  takes  the  same 
course  in  forming  metastases ;  consequently,  it  seems  but  natural 
that  there  should  be  great  difficulty  in  differentiating  the  infec- 
tion as  it  is  produced  by  the  two  bacilli  by  clinical  methods. 
It  is  also  quite  possible  that  bovine  bacilli  may  change  their 
morphology  and  their  characteristics  of  growth  to  suit  the  new 
soil.  It  would  not  tax  our  credulity  in  the  least  to  believe  tJiat 
bacilli  of  the  bovine  type  might  be  taken  into  the  tissues  during 
childhood,  and  by  adapting  themselves  to  the  human  tissues  for 
many  years,  might  assume  characteristics  of  the  human  bacillus 
by  the  time  they  were  ready  to  extend  to  the  lung  or  other 
tissues  and  produce  clinical  disease.  In  fact  this  process  of 
adaptation  might  be  the  reason  for  a  dormant  process  in  a  gland 
taking  upon  itself  activity,  and  the  bacilli  which  had  previously 
been  held  in  check  in  their  growth,  finally  becoming  suited  to 
the  soil  and  multiplying,  inflaming  the  tissues  and  escaping  to 
form  metastases  in  other  parts  of  the  body.5 

Incubation  Period  in  Tuberculosis. — If  we  knew  more  of  the 
incubation  time  in  tuberculosis  it  would  help  somewhat  in  our 
determination  of  the  source  of  infection.  Bartel6  has  described 
a  lymphatic  stage  of  tuberculosis  in  which  the  infectious  organ- 
isms are  viable,  yet  have  not  produced  histological  tubercle. 
Romer  and  Joseph7  have  found  an  incubation    period    of    three 


5Pottenger:_  Some  of  the  Anatomic-Pathologic  Problems  in  Tuberculosis,  Transactions 
of  the  American  Climatological  Association,  1915;  also,  The  Relationship  of  Bovine 
Infection  in  the  Child  to  Clinical  Tuberculosis  in  the  Adult,  Transactions  of  the  Seventh 
Pan-American  Medical  Congress,  San  Francisco,  June  17-21,  1915,  Southern  Medical 
Journal,    November,    1915. 

cDie  Bedeutung  der  L,ymphdruse  als  Schutzorgan  gegen  die  Tuberkuloseinfection,  Wiener 
klinische  Wochenschrift,  Nr.  4,  1905. 

7Prognose  und  Inkubationsstadium  bei  experimentelles  Meerschweintuberkulose,  Ber- 
liner   klinische    Wochenschrift,    1909,    Nr.    28. 


66  SOURCE  AND  ROUTES   OF  INFECTION 

and  a  half  months  in  guinea  pigs.  How  long  this  stage  is  in 
man  we  do  not  know,  yet  we  are  led  to  infer  that  it  is  a  long  one. 

The  fact  that  bacilli  can  pass  through  the  tissues  without  caus- 
ing local  infection  also  makes  the  riddle  more  difficult  to  solve. 
Mucous  membranes  are  readily  penetrated  and  bacilli  are  car- 
ried to  lymph  glands,  at  the  time  of  the  primary  inoculation. 
This  action  on  the  part  of  the  bacillus  differs  from  that  which 
occurs  in  the  formation  of  metastases  after  specific  cell  sensitiza- 
tion has  occurred.  In  a  primary  inoculation  they  may  pass 
through  the  first  glands  and  find  lodgment  in  the  nest  group  or 
the  group  still  further  on,  consequently  we  are  at  a  loss  to  find 
when  and  where  they  gained  access  to  the  tissues. 

Infection  Through  the  Respiratory  Tract. — For  many  years  it 
was  taken  for  granted  that  tuberculosis  was  an  aerogenous  in- 
fection and  that  the  chief  route  of  infection  was  through  the 
inspired  air.  That  the  lungs  were  the  seat  of  involvement  made 
this  seem  certain.  However,  in  recent  times,  the  route  of  infec- 
tion has  been  a  subject  of  wide  discussion. 

Cornet  in  producing  experimental  tuberculosis  in  animals  by 
causing  them  to  inhale  dust  containing  large  numbers  of  tuber- 
cle bacilli  confirmed  the  fact  that  infection  could  take  place  by 
the  aerogenous  route  and  practically  established  this  as  the 
mode  of  infection  for  the  time  being.  It  was  the  original  belief 
that  the  inspired  air  carried  the  bacilli  directly  into  the  alveoli 
of  the  lung ;  and,  in  fact,  this  theory  is  still  held  today  by  many 
men  and  is  supposedly  supported  by  a  great  mass  of  evidence 
such  as  that  brought  forth  by  E.  Albrecht,  H.  Albrecht  and  Ghon, 
who  have  made  thorough  examinations  of  the  lungs  of  children, 
postmortem,  and  have  shown  that  whenever  the  bronchial  or  peri- 
bronchial glands  are  involved  there  is  a  focus,  usually  small,  in 
that  portion  of  the  lung  which  drains  into  these  enlarged  glands. 
This  small  focus  is  taken  to  be  the  primary  focus,  the  enlarged 
glands  to  be  a  metastasis.  This  primary  focus  in  the  pulmonary 
tissue  was  so  commonly  found  in  their  researches  that  they  con- 
sider that  it  establishes  the  aerogenous  route  of  infection  be- 
yond doubt.  Hamburger  accepts  the  results  of  their  investiga- 
tions as  final.  He  says,  the  fact  that  95  per  cent  of  all  bodies 
of  children  who  show  tuberculous  infection  have  both  a  focus  in 
the  lungs  and  infected  bronchial  glands,  is  sufficient  to  establish 


AEROGENOUS  INFECTION  67 

the  inhalation  theory  of  infection;  and,  he  believes  that  the  rea- 
son the  pulmonary  focus  is  so  often  overlooked  is  because  it  is 
small  and  overshadowed  by  the  much  larger  and  visible  glandu- 
lar involvement.8  It  seems  to  me  that  we  must  consider  the  foci 
described  by  these  observers  as  being  possibly  a  result  of  either 
direct  inhalation  or  an  indirect  infection  through  the  blood 
stream,  the  bacilli  entering  through  the  intestinal  mucosa,  and 
being  carried  via  the  lacteals  and  thoracic  duct.  I  have  never 
been  convinced,  however,  that  bacilli  are  commonly  carried  to 
the  alveoli  of  the  lungs  by  the  inspired  air.  In  an  early  paper9 
when  discussing  this  question  I  drew  attention  to  the  protective 
cilia  in  the  anterior  portion  of  the  nose,  the  irregular  mucous 
surfaces  inside  the  nose,  which  are  normally  covered  with  mois- 
ture; the  acts  of  sneezing  called  into  play  when  foreign  sub- 
stances are  lodged  on  the  mucous  surfaces;  the  fact  that  the 
currents  of  air  carrying  the  bacilli  impinge  on  the  moist  sur- 
faces of  the  posterior  wall  of  the  oropharynx  and  that  the  air 
must  then  pass  into  the  lower  air  channels  and  again  follow  a 
course  of  angled  passages,  coming  in  contact  at  every  turn 
with  moist  surfaces,  covered  with  ciliary  epithelium,  which  are 
waving  toward  the  larynx,  before  the  alveoli  are  reached. 

It  would  seem  far  more  probable  that  most  bacilli  which  find 
their  way  into  the  upper  air  passages  are  deposited  on  the 
mucous  membranes  and  are  either  expelled  or  swallowed  or  find 
their  way  through  the  walls  into  the  lymph  spaces  to  be  car- 
ried to  adjacent  glands.  The  fact  that  there  is  no  direct  air 
current  deep  in  the  lungs  would  make  the  direct  passage  of 
bacilli  into  the  alveoli  difficult,  even  though  they  passed  into 
the  larger  air  passages.  In  most  individuals  beyond  the  early 
years  we  must  assume  that  cellular  defense  is  present  which 
makes  implantation  from  without  extremely  difficult. 

Comparison  of  Infection  in  Tuberculosis  and  Definite  Air- 
Borne  Disease. — "We  are  not  in  a  position,  however,  absolutely  to 
deny  that  bacilli  gain  entrance  to  the  lower  air  passages,  partic- 
ularly the  larger  ones  through  the  inspired  air.     We  must  ad- 


8Tuberkulose  der  Kinder,  Handbuch  der  Tuberkulose,  Brauer,  Schroder  und  Blumenfeld, 
id.  v,  1914. 
"The    Mode   of   Infection   in   ' 
of    Tuberculosis,    vol.    v,    1903. 


Bd.  v,  1914. 

"The   Mode   of   Infection   in   Tuberculosis    and   Measures    for   Its    Prevention,    Journal 


68  SOURCE  AND  ROUTES   OF  INFECTION 

mit  that  this  is  probably  the  way  pneumonia,  influenza  and 
bronchitis  establish  themselves,  but  the  specific  germs  which  are 
accountable  for  these  diseases  live  in  a  saprophytic  state  on  the 
walls  of  the  upper  air  passages,  while  tubercle  bacilli  do  not. 
These  diseases  primarily  affect  the  upper  passages  and  then  ex- 
tend toward  the  alveoli.  Tuberculosis,  on  the  other  hand, 
as  we  find  it  in  the  lungs,  is  most  apt  to  start  at  the  apex  and 
travel  downward  through  adjacent  lymph  spaces  or  through  the 
adjacent  bronchi ;  so  the  very  localization  and  subsequent  spread 
of  clinical  pulmonary  tuberculosis  as  compared  with  the  definite- 
ly air-borne  diseases  combats  the  idea  of  direct  aerogenous  in- 
fection. 

Further  than  this,  careful  examination  of  the  air  passages 
of  animals  fails  to  support  this  theory  of  direct  aerogenous  in- 
fection. While  the  nose,  pharynx  and  mouth  show  many  bac- 
teria, the  lungs  of  freshly  killed  animals  are  wholly  or  almost 
wholly  free  from  bacteria.  This  has  been  proved  by  many  in- 
vestigators, among  whom  are  Muller10  and  Bartel.11  That  finely 
divided  dust  particles  can  find  their  way  into  the  lungs  through 
direct  inhalation  of  atmosphere  surcharged  with  it  is  possible. 
We  must  accept  this  as  the  case  in  anthracosis.  We  cannot 
conceive,  however,  of  there  being  any  parallel  between  the  car- 
bon in  the  city  atmosphere  or  in  the  coal  mines  or  the  dust  in 
the  stone  quarries  and  the  tubercle  bacilli  contaminating  inspired 
air.  In  the  former  instance  the  air  is  surcharged  with  particles 
and  inhaled  over  a  prolonged  period  of  time,  while  in  the  case 
of  tubercle  bacilli  there  are  comparatively  few  in  the  air  and, 
as  a  rule,  they  are  not  inhaled  over  a  prolonged  period  of  time. 

The  objection  has  been  made  to  the  experiments  of  Cornet 
that  he  used  dust  so  thoroughly  saturated  with  tubercle  bacilli 
that  the  experiments  were  not  natural.  Further  attention  should 
be  called  to  the  fact  that  in  his  experiments  infection  did  not 
occur  in  the  apex  of  the  lung,  but  in  those  portions  which  di- 
rectly receive  the  inspired  air. 

Droplet  Infection. — Fluege12  brought  forth  the  theory  of  drop- 


10Die  Keimgehalt  der  I^uftwege  bei  gesunden  Thieren,  Mfinchener  Medicinische  Wochen- 
schrift,    1897,    Nr.    49. 

"Ober  den  Bakteriengehalt  der  Iyiiftwege,  Centralblatt  fur  Bakteriologie,  1898,  Bd.  xxiv, 
Heft  11  u  12. 

^Ober  Ivuftinfection,  Zeitschrift  fur  Hygiene  und  Infectionskrankheiten,  Bd.  25,  1897. 


MODES   OP  INFECTION  69 

let  infection.  His  theory  is  that  it  is  not  so  much  the  dry  bacilli, 
mixed  with  dust,  which  are  inhaled  into  the  lung  with  the  in- 
spired air,  but  the  fine  particles  of  bacillus-bearing  secretion 
which  are  thrown  out  by  the  patient  when  coughing  and  sneez- 
ing. These  fine  particles,  according  to  Fluege's  theory,  are  sus- 
pended in  the  air  and  inhaled  directly  into  the  lungs,  in  a  moist 
state  before  the  bacilli  have  been  seriously  injured  by  outside 
environment.  Fluege  has  produced  tuberculosis  in  animals  ex- 
perimentally by  putting  them  in  a  box  and  having  tuberculosis 
patients  cough  over  them.  We  can  say  of  this  experiment,  how- 
ever, the  same  as  of  Cornet's,  that  it  proves  nothing  except  that 
tubercle  bacilli  can  produce  tuberculosis  in  animals  under  con- 
ditions where  sufficient  bacilli  gain  entrance  to  the  tissues.  The 
bacilli  taken  in  through  droplet  infection  should  be  more  viru- 
lent than  those  that  have  dried  and  passed  into  dust.  The  main 
fact  against  this  theory  is  that  the  moist  particles  of  sputum 
carried  in  the  atmosphere  would  moist  likely  be  deposited  on  the 
mucous  membranes  before  they  reach  the  finer  air  passages  of 
the  lung;  in  fact,  it  seems  more  probable  that  these  would  be 
deposited  in  the  oropharynx  and  swallowed. 

Infection  Through  the  Alimentary  Tract. — In  considering  in- 
fection through  the  alimentary  tract  we  include  infection 
through  the  tonsils,  the  mucous  membrane  of  the  mouth  and  oro- 
pharynx, as  well  as  the  entire  lower  portion  of  the  gastroin- 
testinal tract. 

The  theory  of  infection  through  the  alimentary  tract  is  well 
established.  The  ability  of  bacilli  to  withstand  the  action  of 
the  gastrointestinal  secretions  and  the  putrefaction  which  takes 
place  in  the  bowel,  likewise  the  penetrability  of  the  mucous  mem- 
brane of  the  intestinal  tract  has  been  proved.  Bacilli  have  been 
found  in  the  tissues  of  animals  within  a  few  hours  after  their  in- 
gestion. The  fact  is  now  well  established  that  bacilli  prior  to  the 
time  when  a  specific  defense  has  been  established,  pass  through 
mucous  membranes  without  leaving  a  trace  of  their  passage.  It 
is  also  well  established  that  they  pass  through  both  healthy  and 
diseased  mucous  membranes. 

The  experiments  of  Calmette  and  Ravenel  in  feeding  non-in- 
fected dogs  with  tubercle  bacilli  show  the  readiness  with  which 


70  SOURCE  AND  ROUTES   OF  INFECTION 

the  mucous  membranes  are  penetrated.  Until  infection  has  oc- 
curred and  resulted  in  the  endowment  of  the  body  cells  with 
specific  defensive  powers,  we  must  consider  that  little  or  no 
barrier  is  offered  to  the  bacillus  by  the  mucous  membranes;  at 
least,  no  specific  antagonism  is  shown,  no  special  attempt  to  pre- 
vent the  bacilli  from  entering  the  body.  The  mucous  membranes 
are  more  like  meshes  which  permit  an  easy  penetration,  the 
bacilli  passing  on  to  be  caught  in  the  lymph  glands;  but,  after 
the  cells  have  developed  a  specific  power  of  defense,  opposition 
is  offered  by  the  local  cells  and  the  mucous  membranes  them- 
selves become  resistant,  otherwise  how  can  we  account  for  the 
resistance  of  the  air  passages  and  intestines  in  advanced  pul- 
monary tuberculosis  ?13 

If  the  bacilli  swallowed  by  the  average  advanced  tuberculous 
patient  penetrated  mucous  membranes  as  readily  as  they  do  in 
the  non-infected,  there  would  be  no  chance  for  the  patient.  The 
infiltration  and  ulceration  of  the  intestines  in  advanced  tuber- 
culosis must  be  looked  upon  as  an  attempt  on  the  part  of  the 
cells  to  exercise  their  specific  protective  powers  against  the 
bacillus.  The  infection  is  from  surface  inoculation  and  the  in- 
filtration or  ulceration  is  the  result  of  the  inflammation  which 
takes  place  between  the  sensitized  cells  and  the  bacilli  and  must 
be  looked  upon  as  an  expression  of  an  attempt  to  eliminate  the 
bacilli'  instead  of  allowing  them  to  pass  into  the  deeper  tissues. 

The  writer  was  early  convinced  that  lymphatic  infection  in 
childhood  stood  in  a  close  relationship  to  the  clinical  disease  in 
the  adult  and  discussed  this  question  before  the  Twenty-ninth 
Semi-Annual  Meeting  of  the  Southern  California  Medical  Asso- 
ciation in  May,  1902.14  At  that  time  we  did  not  have  the  various 
tuberculin  tests  which  have  proved  so  valuable  in  studying  this 
disease  in  childhood.  My  observations  were  based  on  the  fre- 
quency of  glandular  tuberculosis  found  in  children  postmortem 
and  the  clinically  enlarged  lymphatic  glands  which  were  later 
followed  by  tuberculosis  in  the  same  individual. 

The  observations  of  Bios15  who  followed  the  after  history  of 


MPottenger:  Some  of  the  Anatomic-Pathologic  Problems  in  Tuberculosis,  Transactions 
of  the  American   Climatological   Association,    1915. 

"Tuberculosis  of  Childhood  With  Special  Reference  to  Infection,  Southern  California 
Practitioner,  June,   1902. 

"Mitteilungen  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie,   1899,  Nr.  iv. 


ALIMENTARY  INFECTION  71 

160  cases  of  tuberculosis  of  the  lymphatic  glands  from  Czerney's 
clinic  in  Heidelberg  for  a  period  of  from  three  to  twelve  years 
and  found  that  40  per  cent  developed  clinical  tuberculosis,  were 
quoted.  He  states:  "Just  what  per  cent  of  the  cases  of  tuber- 
culosis in  adults  is  due  to  this  lymphatic  infection  during  child- 
hood we  are  unable  to  say;  yet,  it  is  a  source  of  infection  that 
deserves  much  more  consideration  than  it  has  hitherto  received." 

Von  Behring16  announced  the  important  fact  that  the  intestinal 
tract  of  the  newly  born  is  especially  easily  penetrated  by  bacilli. 
He  further  asserted  that  tuberculosis  is  a  disease  which  enters 
the  human  body  through  the  intestinal  tract,  that  childhood 
is  the  time  of  infection,  and  that  the  source  of  infection  is  al- 
most wholly  milk.  While  this  latter  has  not  been  substantiated, 
childhood  as  the  time  of  infection  and  the  alimentary  canal  as 
the  chief  portal  of  entry  has  been  rapidly  gaining  adherents. 

When  the  idea  of  alimentary  infection  was  first  suggested, 
those  who  opposed  it  put  forth  the  argument  against  it  that  the 
intestine  and  glands  of  the  mesentery  are  not  usually  infected; 
but  later  experiments  have  shown  that  this  is  not  necessary. 
Bacilli  may  pass  through  the  mucous  membrane,  be  taken  up 
by  the  lymphatics,  carried  by  way  of  the  thoracic  duct  and 
poured  into  the  subclavian  vein  to  be  strained  out  in  the  lung 
or  other  organs.  It  is  further  possible  that  infectious  material 
may  pass  through  the  mesenteric  glands  and  on  into  the  medi- 
astinal glands  the  same  as  bacilli  may  pass  from  the  tonsils 
through  the  superficial  cervical  down  into  the  deep  cervical 
and  possibly  on  into  the  mediastinal  glands.  This  latter  possibil- 
ity, however,  is  not  supported  by  Most's17  anatomical  studies. 

Kabinowitsch  and  Oberwarth18  injected  tubercle  bacilli  into 
the  rectum  of  animals  and  showed  that  they  were  taken  up  and 
carried  into  the  intestinal  glands  and  that  they  were  also  taken 
into  the  blood  and  found  in  the  lungs.  From  studies  of  the  in- 
testinal tract  we  know  that  material  injected  into  the  rectum 
passes  rapidly  toward  the  ileo-cecal  valve  and  when  patulent 
even  passes  beyond  it.    The  above  experiment  shows  that  tubercle 


a^Tuberkulosebekampfurg,  Marburg,  1903. 

17Die  Topographie  des  Lymphgefassapparates  des  Menschlichen  Korper  und  ihre  Bezie- 
hungen  zur  den   Infektionswegen   der  Tuberkulose,   Stuttgart,    1908. 

18Ober  die  Resorptionsinfektion  mit  Tuberkelbazillen  vom  Magendarmkanal,  Berlin  klin- 
lsche    Wochenschrift,    1908. 


72  SOURCE   AND   ROUTES    OF   INFECTION 

bacilli  may  be  taken  in  through  the  mucous  membrane  of  the 
intestinal  tract  and  carried  directly  to  the  lung,  although  it 
does  not  reveal  the  point  of  entry;  consequently,  it  is  possible 
to  have  what  seems  to  be  a  primary  infection  of  the  lung  take 
place  through  the  intestinal  tract.  This  suggests  an  explanation 
aside  from  that  of  direct  inhalation  for  the  cases  described  by 
Ghon,  the  Albrechts  and  Kuss. 

The  confusion  arising  from  the  interpretation  of  inoculation 
experiments  is  due  to  the  fact  that  the  inoculations  are  carried 
out  in  an  unnatural  way.  Much  larger  doses  of  bacilli  are  em- 
ployed than  would  be  found  in  normal  inoculations,  and  they 
are  taken  into  the  body  in  ways  that  are  unnatural ;  consequently, 
conclusions  that  are  drawn  must  be  more  or  less  guarded. 

In  connection  with  the  experiments  with  bacilli  we  must  men- 
tion those  of  Calmette  and  others  in  the  production  of  anthra- 
cosis  by  injecting  the  soot  particles  into  the  alimentary  canal. 
Schultze19  says  in  discussing  his  experiments  with  the  ingestion 
of  India  ink:  "It  is  the  mediastinal  glands  Avhich  are  first  and 
most  involved.  They  show  color  before  the  lung  tissue  itself." 
And  again:  "One  can  say  with  the  greatest  certainty  that  the 
particles  pass  through  the  lymph  channels  and  thoracic  duct 
into  the  blood  stream."  These  experiments  show  unnatural  con- 
ditions, but  prove  that  the  path  from  the  intestinal  tract  to  the 
lungs  or  bronchial  glands  is  an  open  one.  He  further  states 
that  he  finds  the  spleen,  liver,  kidney  and  other  organs  to  con- 
tain small  particles  as  well.  This  same  has  been  shown  by 
others  who  have  carried  on  their  experiments  by  inhalation, 
among  whom  are  Sluka.20 

Not  only  must  we  consider  the  ingestion  of  tubercle  bacilli 
along  with  food  or  drink,  but  we  must  consider  the  possibility 
of  children  infecting  themselves  through  bacilli  that  are  carried 
to  the  mouth  from  their  fingers  after  playing  on  the  floor  or 
handling  infected  articles.  We  must  also  consider  the  possibility 
of  bacilli  being  taken  in  with  inspired  air  and  being  deposited 
on  the  moist  surfaces  of  the  oropharynx,  either  passing  through 


a9Intestinaler  Ursprung  der  Lungenanthrakose,  Zeitschrift  fur  Tuberkulose,  Bd.  ix, 
Heft  5,    1906. 

^Uber  die  Wanderung  korpuskular  Elementen  im  Organism,  Prager  Medizinische 
Wochenschrift,   1898. 


INFECTION   THROUGH   TONSILS  73 

the  mucous  membranes  or  the  tonsils  or  being  swallowed  and 
then  causing  infection  through  the  intestinal  wall. 

Nagelsbach  examined  the  dirt  taken  from  under  the  finger 
nails  of  children  and  found  tubercle  bacilli  present  in  quite  a 
percentage  of  the  specimens. 

Tonsils. — The  tonsils  have  been  considered  a  point  of  entry 
for  tuberculosis  for  many  years.  Some  authors  such  as  Grober21 
starting  with  the  idea  as  suggested  by  Aufrecht,  that  in  82  per 
cent,  and  according  to  Naegeli,  90  per  cent,  and  according  to 
Cornet  in  practically  all  cases  of  pulmonary  tuberculosis,  the 
primary  infection  is  at  the  apex,  tried  to  show  that  there  must 
be  some  direct  relationship  between  the  portal  of  entry  and  the 
apex  of  the  lung.  Accordingly  Grober  made  an  extensive  study 
in  which  he  endeavored  to  show  that  tubercle  bacilli  are  taken 
into  the  human  body  through  the  tonsils,  pass  down  into  the 
cervical  glands  and  cross  over  the  pleural  lake  directly  into  the 
apex.  This,  however,  has  not  been  generally  accepted.  Most22 
in  his  studies  of  the  anatomy  of  the  lymphatic  system  fails  to 
furnish  an  anatomical  basis  for  such  lymphatic  connection  as 
previously  mentioned.  We  cannot  deny,  however,  that  the  ton- 
sil and  other  lymphatic  tissue  in  the  pharynx  bear  an  important 
relationship  to  infection  in  tuberculosis  the  same  as  Ave  now 
know  it  in  other  infections  (see  Figs.  13  and  14,  pages  93  and  94). 

Aufrecht  made  an  examination  of  10  tonsils  in  which  he 
found  tubercle  bacilli  twice,  and  16  adenoids  in  which  he  found 
tubercle  bacilli  three  times,  thus  making  in  this  small  number 
20  per  cent  in  the  tonsils  and  19  per  cent  in  the  adenoids. 

Dieulafoy23  extirpated  hypertrophied  tonsils  and  adenoids  and 
inoculated  them  into  guinea  pigs.  Of  61  hypertrophied  tonsils, 
5  or  13  per  cent  caused  infection.  Of  35  adenoids  7,  or  20  per 
cent  produced  infection. 

Such  experiments  as  these  show  that  tonsillar  tissue  does  con- 
tain tubercle  bacilli  and  inasmuch  as  the  histological  tubercle 
is  not  present  we  must  assume  that  the  bacilli  are  there  in  the 


^Die  Tonsillen  als  Eintrittspforten  fur  Krankheitserreger  bezonders  fur  den  Tuberkel- 
bazillus,    Gustav   Fischer,    Jena,    1905. 

22Die  Topographie  der  fur  die  Infektionswege  der  Lungentuberkulose  massgebenden 
Lymphbahen,   VI   Internationale   Tuberkulosenkonferenz,    1907,   Bericht    S.    132. 

^Bulletin  de  l'academie  de  medicine,  1895,  Nr.  17-20.  Cited  by  Kossel,  Zeitschrift  fur 
Hygiene,   1896,  Bd.   21,   S.  68. 


74  SOURCE  AND  ROUTES  OP  INFECTION 

process  of  being  destroyed  or  passing  through  the  gland,  the 
same  as  they  pass  through  the  mucous  membranes  of  the  air  pas- 
sages and  intestinal  tract.  Their  course  after  passing  through 
the  tonsils  is  first  directed  into  the  cervical  glands  and  from 
there  it  is  just  as  simple  for  them  to  pass  into  the  blood  stream 
and  be  carried  to  the  apex  of  the  lung  as  it  would  be  for  bacilli 
to  be  carried  from  the  peribronchial  or  glands  in  any  other  por- 
tion of  the  body.  The  entrance  of  tubercle  bacilli  or  any  other 
microorganisms  through  the  tonsils  is  favored  not  only  by  the 
character  of  the  tonsillar  tissue,  but  also  by  the  peculiar  position 
which  the  tonsils  occupy  in  the  throat.  The  same  might  also  be 
said,  only  the  position  is  not  as  favored,  of  the  adenoid  tissue 
and  the  mucous  membranes  of  the  oropharynx  in  general.  The 
tonsillar  tissue  in  particular  has  many  crypts.  There  is  consider- 
able force  exerted  in  the  act  of  swallowing  and  this  force  must 
press  food  particles,  and,  with  it,  bacteria  strongly  against  the 
tonsils  and  the  mucous  membrane  of  the  oropharynx  and  in  this 
way  favor  the  passage  of  bacilli  into  the  tissues.  That  bacilli  may 
pass  through  the  tonsils  and  cause  infection  must  not  be  taken  as 
an  argument  in  favor  of  the  indiscriminate  removal  of  the  tonsils. 
The  importance  of  infection  through  the  alimentary  tract  has 
been  greatly  accentuated  by  the  study  of  the  intertransmissibil- 
ity  of  human  and  bovine  tubercle  bacilli.  If  the  theory  of  bovine 
infection,  particularly  milk  infection,  is  to  hold,  the  alimentary 
tract  must  furnish  an  important  portal  of  entry.  While  this 
question  does  have  a  very  important  bearing  upon  the  question 
of  intertransmissibility,  it  has  a  much  wider  meaning  in  the  gen- 
eral infection  of  the  human  body  by  tubercle  bacilli  regardless 
of  the  source.  It  is  impossible  for  us  to  believe  that  all  infec- 
tion is  accounted  for  by  the  inhalation  of  bacillus  laden  dust 
and  the  ingestion  of  infected  milk.  That  this  is  true  is  evi- 
dent if  we  study  tuberculosis  as  we  find  it  in  inhabitants  of  dif- 
ferent countries.  For  example,  the  great  amount  of  tubercu- 
losis in  all  forms  that  is  present  in  Japan  where  comparatively 
little  milk  is  used,  shows  that  infection  through  the  ingestion  of 
milk  is  not  a  necessary  factor.  Tuberculosis  found  in  the  United 
States  where  large  quantities  of  milk  are  used,  assumes  the  same 
forms  as  it  does  in  Japan. 


ALIMENTARY  INFECTION  75 

In  a  recent  paper,  Kavenel,24  in  an  interesting  discussion  of 
the  question  of  the  modes  of  infection,  gives  a  very  valuable 
historical  presentation  of  the  more  important  studies  in  infec- 
tion through  the  digestive  tract.  Because  of  the  practical  impor- 
tance of  this  discussion  I  quote  as  follows : 

"Infection  Through  the  Digestive  Tract. — The  first  recorded 
cases  of  infection  through  the  digestive  tract  are  those  of  Klenke, 
who  in  1846  gave  the  histories  of  sixteen  children  who  had  been 
fed  on  cow's  milk,  and  all  of  whom  showed  tuberculosis  of  the 
intestines,  glands,  skin  or  bones. 

"Previous  to  this,  however,  Carmichael,  in  1810,  recorded  as 
his  observation  that  he  had  frequently  seen  the  mesenteric  glands 
strumous  without  involvement  of  the  external  glands,  and  this 
led  him  to  believe  that  in  scrofula  the  mesenteric  glands  were 
first  involved.  He  referred  to  the  frequency  of  a  disease  similar 
to  scrofula  seen  in  pigs  fed  on  sour  milk,  and  called  attention 
to  the  common  occurrence  of  bowel  trouble  in  children  at  the 
time  of  weaning  'too  often  followed  by  disease  of  mesenteric 
and  lymphatic  glands.' 

"Casper,  in  1882,  referred  to  the  extent  of  tuberculosis  ('nodu- 
lar consumption')  among  the  milch  cows  of  Paris,  and  said,  'It 
is  possible  that  there  is  a  connection  between  this  phenomenon 
and  the  many  tuberculous  diseases  among  the  children  of  Paris.' 

"Experimental  evidence  of  tuberculous  infection  in  cattle  by 
feeding  was  given  as  early  as  1868,  by  Chauveau,  who  extended 
his  work  with  corroborative  results  in  1872  and  1873 ;  and  Vil- 
lemin  in  1869  obtained  positive  results  by  feeding  in  rabbits 
and  guinea  pigs.  He  was  the  first  to  employ  a  tube  for  the  in- 
troduction of  tuberculous  material  into  the  stomach.  Experi- 
ments by  scientists  of  every  nation  have  given  positive  support 
to  the  work  of  these  early  observers.  It  is  also  a  well-known 
and  widely  observed  fact  that  in  the  spread  of  tuberculosis  of 
cattle  and  swine  the  digestive  tract  plays  a  most  important  role. 
Swine  particularly  are  infected  through  the  digestive  tract  in 
the  great  majority  of  cases,  and  the  ingestion  of  milk  from 
tuberculous  cattle  is  universally  recognized  as  one  of  the  chief 


24Present  Views  in  Respect  to  Modes  and  Periods  of  Infection  in   Tuberculosis,   Jour- 
nal American   Medical  Association,   February  26,    1916. 


76  SOURCE  AND   ROUTES   OF  INFECTION 

factors  in  the  spread  of  the  disease  among  these  animals.  The 
first  examination  made  by  the  officers  of  the  Federal  Meat  In- 
spection Service  is  based  on  this  fact.  In  93.3  per  cent  of  cases, 
tuberculous  hogs  show  infection  of  the  cervical  glands. 

"  'As  the  disease  is  essentially  produced  by  ingestion,  the 
glands  and  tissues  associated  with  the  digestive  tract  are  the  most 
frequent  seats  of  infection.  Indeed,  the  superior  cervical  glands 
(in  almost  all  cases  the  submaxillary  gland)  are  nearly  always 
affected,  as  at  the  postmortem  examination  held  by  bureau  in- 
spectors over  a  consecutive  period  on  120,000  tuberculous  hog 
carcasses,  93.3  per  cent  were  found  to  contain  lesions  in  these 
glands.  The  large  tonsils  and  the  large  number  of  lymph  sinuses 
in  the  lymph  glands  probably  account  for  this  great  frequency.' 

"  'From  some  records  relative  to  the  locations  of  tuberculous 
lesions  in  cattle  that  were  made  at  the  same  time  that  the  figures 
pertaining  to  hogs  were  collected,  it  appears  that  in  tuberculous 
cattle  the  lesions  of  tuberculosis  were  located  in  the  cervical 
glands  in  66%  per  cent  of  the  animals,  in  the  bronchial  glands 
in  54.5  per  cent,  and  in  the  mediastinal  glands  in  63.6  per  cent.' 

"In  1901,  in  his  London  address,  while  discussing  the  rela- 
tion of  bovine  tuberculosis  to  human  death,  Koch  took  the 
ground  that  infection  through  food  could  be  assumed  to  have 
taken  place  with  certainty  only  when  the  primary  tuberculous 
lesion  was  located  in  the  intestines.  He  asserted  that  this  was 
rarely  found  to  be  the  case,  and  argued  that  the  danger  of  in- 
fection through  food  was  slight.  The  stand  taken  by  Koch 
assumed  that  the  tubercle  bacillus  was  unable  to  gain  entrance 
to  the  system  through  the  intestinal  wall  without  the  production 
of  a  lesion  at  the  point  of  entrance. 

"The  question  raised  by  Koch  has  been  thoroughly  investi- 
gated, and  it  can  be  said  with  certainty  that  the  tubercle  bacil- 
lus can  penetrate  the  mucous  membrane  of  the  upper  digestive 
tract  as  well  as  that  of  the  intestine  readily  and  quickly,  with- 
out producing  a  tuberculous  lesion  at  the  point  of  entry.  By 
Baumgarten,  however,  it  is  held  that  there  is  always  a  focus  of 
infection  at  the  point  of  entrance  sooner  or  later,  even  though 
it  may  be  microscopic.     Against  this  is  the  demonstration  by 


ALIMENTARY  INFECTION  77 

von  Behring  and  Roemer  of  the  ready  permeability  of  the  in- 
testinal mucosa  of  young  animals  by  various  bacteria — even 
the  large  anthrax  bacillus.  In  1,000  swine,  infected  through 
food,  Ostertag  found  the  glands  of  the  throat,  neck  and  mesen- 
tery tuberculous,  while  the  mucous  membrane  of  the  intestine 
was  always  free  from  disease.  Orth,  in  1879  and  Cornet,  in  1880, 
observed  bacilli  pass  step  by  step  through  the  fully  developed 
mucous  membrane  of  the  uninjured  intestine  and  reach  the  lymph 
channels  and  mesenteric  glands,  leaving  no  recognizable  trace 
behind  (Furst).  Dobroklonski,  in  1890,  working  under  Cornil, 
showed  that  the  tubercle  bacillus  would  quickly  penetrate  the 
healthy  wall  of  the  intestine  in  guinea  pigs.  Desoubry  and 
Porcher,  students  of  Nocard,  showed  in  dogs  that  during  the  di- 
gestion of  fats  large  numbers  of  bacteria  were  carried  through 
the  intestinal  wall  and  could  be  detected  in  the  chyle  within  a 
few  hours  after  the  meal  was  given.  If  food  free  from  fat  was 
given,  few  or  even  no  bacteria  could  be  found.  Nicolas  and 
Descos,  in  1902,  found  that  tubercle  bacilli  given  to  dogs  in  fatty 
food  reached  the  chyle  within  three  hours.  During  feeding  ex- 
periments conducted  at  the  laboratory  of  the  State  Live  Stock 
Sanitary  Board  of  Pennsylvania,  we  frequently  observed  exten- 
sive tuberculosis  of  the  lungs  and  thoracic  glands  in  animals  which 
showed  slight  or  even  no  involvement  of  the  intestine.  In  1902- 
1903  I  introduced  into  the  stomach  of  a  number  of  dogs  tubercle 
bacilli  suspended  in  an  emulsion  of  melted  butter  and  warm 
water,  using  a  tube  in  order  to  prevent  possible  infection  through 
the  trachea.  The  dogs  were  killed  after  three  and  one-half  to  four 
hours,  during  active  digestion,  as  much  chyle  as  possible  was  col- 
lected, and  the  mesenteric  glands  were  removed.  Guinea  pigs 
were  inoculated  with  this  material.  Tubercle  bacilli  were  demon- 
strated in  abundance  in  eight  of  ten  experiments.  The  dogs  were 
kept  on  soft  food  for  some  days  before  the  experiments,  and  were 
purged  with  castor  oil,  in  order  to  rid  the  intestine  of  all  foreign 
matter  which  might  injure  the  mucous  membrane.  Numerous  sec- 
tions of  the  intestine  were  examined  also,  but  no  injury  could  be 
detected. 

"It  is  possible  here  only  to  mention  the  work  of  Calmette  and 


78  SOURCE  AND  ROUTES   OF  INFECTION 

his  students,  as  a  result  of  'which  he  concluded  that  pulmonary 
tuberculosis  acquired  at  any  age  may  be  due  to  recent  intestinal 
infection. 

"The  rapidity  with  which  tubercle  bacilli  penetrate  the  intes- 
tine and  reach  the  lung  through  the  thoracic  duct  is  remarkable. 
Besanti  and  Panisset  found  that  when  fed  to  dogs  in  soup  they 
reached  the  heart  blood  within  from  four  to  five  hours.  Bartel 
found  that  after  a  single  dose  they  penetrated  the  uninjured  in- 
testine and  reached  the  mesenteric  glands  during  the  following 
digestive  period.  Schlossmann  and  Engel,  by  inoculating  tuber- 
cle bacilli  suspended  in  cream  into  the  stomachs  of  young  guinea 
pigs  through  an  incision  in  the  abdominal  wall,  demonstrated 
that  they  reached  the  lung  within  six  hours.  Their  work  has 
been  confirmed  by  Eavenel  and  Eeichel.  Rabinowitsch  and  Ober- 
warth  established  nutrition  through  a  gastric  fistula  in  swine, 
and  then  resected  the  esophagus,  after  which  tubercle  bacilli  were 
introduced  into  the  stomach.  "Within  twenty-four  hours  they  were 
shown  to  have  penetrated  to  many  organs  of  the  body." 

Difficulty  in  Determining  Source  of  Infection. — Jacob  in  his 
exhaustive  study  of  the  children  in  the  country  districts  of  Ger- 
many, shows  that  tuberculosis  is  very  prevalent  and  found  in 
families  where  there  have  been  no  open  cases  of  tuberculosis  for 
many  years,  among  children  who  do  not  make  milk  their  princi- 
pal article  of  food;  so  it  seems  to  me  that  we  must  not  look  for 
other  sources  of  infection  and  other  routes  of  bacilli  so  much  as 
for  other  methods  of  carrying  the  bacillus  and  other  bacillus 
carrying  material. 

Jacob  suggests  the  fly  as  a  carrier  and  is  of  the  opinion  that 
it  is  a  big  factor.  Here,  however,  we  must  remember  that  flies, 
as  a  rule,  do  not  go  far  from  the  place  of  their  birth,  consequent- 
ly they  will  not  carry  the  disease  to  any  great  distance.  Is  it 
not  possible  that  one  source  of  infection  in  tuberculosis  is  articles 
of  food  that  are  prepared  and  handled  by  tuberculous  people,  or 
food  that  is  exposed  to  dust  that  contains  tubercle  bacilli.  Fur- 
ther, is  it  not  possible  that  in  the  handling  of  wares  of  different 
kinds  that  tubercle  bacilli  are  carried  into  the  homes  in  suf- 
ficient amounts  to  infect  children?    The  infecting  bacillus  is  so 


DIFFICULTY  IN  DETERMINING  SOURCE   OF  INFECTION  79 

ubiquitous  that  we  must  recognize  the  fact  that  it  is  brought  to  the 
body  in  many  different  ways,  and  not  be  content  by  thinking  that 
it  is  simply  inhaled  through  dust  and  ingested  with  milk;  other- 
wise, how  can  we  account  for  the  numbers  of  infected  children 
who  seem  to  be  removed  from  these  more  common  sources  of  in- 
fection? 

Jacob  examined  the  flies  in  nineteen  peasant's  houses  and 
found  tubercle  bacilli  on  the  feet  in  6  or  31.5  per  cent.  This  is 
sufficient  to  condemn  the  fly  and  call  for  its  extermination. 

Jacob  examined  2,744  children  in  27  villages  in  the  country 
districts  of  Huemmling.  Of  these,  920  reacted  positively  to  tuber- 
culin and  1,829  proved  negative.  The  920  children  who  showed 
a  positive  reaction,  lived  in  620  houses.  Among  these  were  237— 
38.2  per  cent  of  houses  in  which  during  the  last  decade  one  or 
several  members  of  the  family  had  died  or  suffered  from  tuber- 
culosis. The  remaining  383  houses,  equal  to  61.8  per  cent  had 
previously  shown  no  cases  of  tuberculosis.  The  1,829  children 
reacting  negatively  lived  in  526  houses.  Of  these  154 — 29.4  had 
housed  tuberculous  patients  and  372  or  70.6  per  cent  of  the  houses 
had  not  contained  a  single  case  of  tuberculosis. 

In  these  statistics  it  will  be  seen  that  383,  or  61.8  per  cent  of 
the  620  houses  in  which  these  children  who  showed  a  positive 
reaction,  lived,  had  not  housed  patients  suffering  from  tubercu- 
losis. 

He  also  examined  children  who  were  not  going  to  school  in 
villages  which  had  been  free  from  tuberculosis  and  found  that 
from  30  to  40  per  cent  of  the  children  were  infected.  Jacob  ex- 
cludes milk  as  being  the  principal  factor  in  this  infection,  for 
he  says  that  in  these  districts  the  children  are  mostly  breast  fed 
and  are  often  nursed  during  the  entire  period  of  the  first  two 
years  of  life ;  and,  he  calls  attention  to  the  fact  that  owing  to  the 
care  which  the  mothers  give  their  children  and  the  advantage  of 
breast  feeding,  the  mortality  among  these  children  is  exceedingly 
low.  Of  600  children  born  each  year,  the  mortality  is  only  11.7 
per  cent  the  first  year.  He  then  compares  this  low  death  rate 
with  the  death  rate  for  Bavaria  in  the  year  1909.  In  Oberfranken 
the  mortality  was  15  to  20  per  cent,  in  Mittlefranken  it  was  24 


80  SOURCE  AND  ROUTES   OF  INFECTION 

to  30  per  cent,  and  in  Schwaben  and  Neiderbayern  it  was  26  to 
30  per  cent. 

These  statistics  of  Jacob  are  of  great  importance  in  their  bear- 
ing upon  the  method  of  carrying  infection.  Here  we  have  a 
large  body  of  children  who  were  free  from  contact  with  tuber- 
culous individuals,  who  have  never  lived  in  homes  occupied  by 
tuberculous  patients,  who  were  fed  on  breast  milk  until  the  sec- 
ond year  and  in  whom  the  general  mortality  is  much  lower  than 
that  usual  among  children;  yet  a  large  percentage  of  them  show 
infection  before  the  school  age. 

Other  Methods  of  Infection. — While  infection  through  the  re- 
spiratory and  gastrointestinal  tracts  will  most  probably  account 
for  nearly  all  cases  of  tuberculosis,  yet  it  is  necessary  to  mention 
that  tubercle  bacilli  may  be  taken  in  through  the  skin.  This  at 
times  we  see  in  local  tuberculosis  of  the  fingers  and  hands  of 
those  who  perform  many  postmortems  on  tuberculous  subjects, 
also  on  the  hands  of  those  who  handle  tuberculous  meat.  It  is 
also  possible  that  infection  might  take  place  through  other  mucous 
membranes  such  as  those  of  the  genitourinary  tract;  but  such  in- 
fections are  comparatively  rare. 

No  matter  how  the  bacillus  is  taken  into  the  body,  unless  de- 
stroyed, it  follows  one  of  two  courses  after  it  gains  access  to  the 
tissues.  It  either  forms  the  tuberculous  focus  where  it  settles; 
or,  which  is  far  more  common,  it  passes  into  the  lymphatic  spaces 
and  is  carried  to  the  neighboring  glands  or  to  other  glands  where 
it  forms  a  primary  focus ;  or  it  is  taken  up,  as  it  sometimes  is  in 
the  case  of  the  gastrointestinal  tract,  by  the  lymphatics  and  car- 
ried to  the  thoracic  duct  and  poured  directly  into  the  blood 
stream. 

The  spreading  of  the  disease  from  the  primary  focus  in  the 
lymph  glands  takes  place  either  by  bacilli  penetrating  the  walls 
of  blood  vessels  and  being  carried  to  the  lungs  or  other  parts  of 
the  body,  or  through  the  wandering  cells;  or  directly  through 
the  lymph  itself.  In  this  connection  it  must  be  remembered  that 
infection  may  follow  the  back  flow  of  lymph  as  well  as  the  on- 
ward flow  (Tendeloo).  It  is  possible  that  the  adaptability  of  the 
tissues  to  infection  and  to  the  particular  strain  of  bacilli'"(Rose- 
now)  are  factors  in  determining  the  secondary  localization  of  the 


HUMAN   AND   EXPERIMENTAL   TUBERCULOSIS   DIFFER  81 

bacilli.  Iii  the  human  race  we  find  primary  tuberculosis  in  the 
glands  and  metastatic  infection  most  usually  in  the  lungs  of 
adults,  while  in  rabbits  the  lungs  and  kidneys  are  usually  in- 
volved and  in  guinea  pigs  very  often  the  spleen  is  involved.  With 
reference  to  these  infections  in  animals  we  must  bear  in  mind 
that  they  are  infections  on  virgin  soil,  in  which  specific  cellular 
defense  has  not  been  developed,  consequently,  there  is  not  this 
specific  inflammatory  reaction  which  takes  place  between  bacilli 
and  specific  enzymes  to  prevent  widespread  dissemination.25 


25Pottenger:      Tuberculin    Therapy — Its    Present    Imperfections    and    Future    Improve- 
ments, Medical  Record,  February  20,   1915. 


CHAPTER  III. 

RELATIONSHIP  OF  THE  PRIMARY  FOCUS  TO  CLINICAL 

TUBERCULOSIS. 

Differentiation  Between  Primary  Focus  and  Primary  Metas- 
tasis.— In  the  following  discussion  I  shall  speak  of  the  primary 
focus,  meaning  the  first  area  of  infection  which  takes  place  in  the 
body;  and  of  the  primary  metastasis,  meaning  an  area  of  infec- 
tion which  occurs  in  some  part  of  the  body,  the  bacilli  causing 
the  same  having  come  from  the  primary  focus.  Secondary  metas- 
tases are  those  which  are  formed  by  bacilli  which  escape  from 
a  previous  metastasis. 

It  will  be  seen  at  once  that  the  primary  focus  is  an  infection  in 
a  previously  uninfected  organism,  while  metastases  occur  in  or- 
ganisms which  have  already  been  infected.  These  two  types  of 
infection  are  very  different;  the  former  occurs  without  the  op- 
position of  specific  defense  and  the  latter  is  opposed  by  the  specific 
resistance  which  has  been  developed  by  the  body  cells.  In  com- 
paring the  phenomena  which  are  associated  with  primary  infec- 
tion with  those  associated  with  metastatic  infection,  particularly 
the  phenomena  which  occur  in  connection  with  the  lymph  glands 
which  receive  the  drainage  from  the  tissues  affected,  the  same 
relationship  is  apparent  as  is  noted  between  the  seat  of  inocula- 
tion and  the  regional  lymph  glands  in  Koch's  inoculation  ex- 
periments which  have  been  quoted  so  much  in  our  recent  studies 
of  hypersensibility.  If  the  same  principles  hold,  and  I  see  no 
reason  why  they  should  not,  we  can  determine  whether  or  not  a 
lesion  in  the  lung  is  a  primary,  or  a  secondary,  or  metastatic 
infection  by  investigating  the  manner  in  which  the  glands  be- 
have toward  the  focus  of  infection. 

It  will  be  recalled  that  Koch's  experiment  shows  that  the  inocu- 
lation of  a  previously  healthy  animal  with  tubercle  bacilli  pro- 
duces very  little  disturbance  at  the  point  of  inoculation;  but 
the  bacilli  are  taken  up  and  at  once  carried  to  the  regional  lymph 


Ej 

if    HJv 

F 

Fig.    12  A. 


Fig.    125. 


Fig.  12,  y2  and  B. — Illustrating  schematically  the  difference  in  behavior  of  tissues  toward 
invading  bacilli.  Fig.  12A,  when  specific  defense  has  not  been  established  by  previous  in- 
fection; Fig.  12B,  when  specific  defense  has  been  established  by  previous  infection.  In 
Fig.  \2A  the  bacilli  pass  through  the  mucous  membrane  C-D  and  the  tissues  beyond  and 
are  carried  directly  into  the  lymphatic  gland  G.  In  Fig.  125,  they  do  not  pass  through 
the  mucous  membrane  E-F  readily,  but  are  held  at  the  point  of  implantation.  The  tissues 
between  the  mucous  membrane  and  the  gland  G,  as  well  as  the  gland  itself,  are  free  from 
invading  bacilli. 


PRIMARY  AND  METASTATIC  TUBERCULOSIS  83 

glands  where  a  marked  infection  is  established.  However,  after 
infection  has  once  been  established  in  the  body,  the  behavior  of 
the  tissues  is  very  different.  They  are  now  on  guard  against 
tubercle  bacilli  and  attempt  to  destroy  them  at  the  site  of  inocu- 
lation and  prevent  their  implantation.  This  condition  we  de- 
scribe as  sensitization  of  the  body  cells.  It  means  a  condition  in 
which  the  cells  are  able  to  offer  specific  resistance.  Through  the 
original  infection  all  body  cells  have  been  changed  so  that  they 
now  offer  a  specific  protection  against  any  new  bacilli  which  at- 
tempt to  enter  the  tissues ;  consequently  there  is  produced  in  an 
animal  which  is  already  tuberculous,  when  inoculated  a  second 
time,  an  induration  at  the  point  of  inoculation  followed  sooner 
or  later  by  ulceration,  the  regional  lymph  glands  not  being  in- 
volved or  being  involved  only  slightly.  Figs.  12A  and  125  illustrate 
schematically  the  difference  in  behavior  between  bacilli  and  the 
tissues  prior  to  and  after  the  development  of  specific  cellular  de- 
fense.   Specific  defense  is  due  to  specific  enzymes. 

In  the  primary  pulmonary  foci  described  by  Ghon,  he  calls  at- 
tention to  the  insignificance  of  the  pulmonary  lesion  and  the  man- 
ner in  which  it  is  overshadowed  by  the  marked  swelling  of  the 
regional  bronchial  glands  which  receive  drainage  from  the  pul- 
monary tissue  involved.  This  is  markedly  different  from  the 
metastatic  foci  which  occur  in  the  lung  later  in  life  in  which  the 
swelling  of  the  lymph  glands  plays  such  a  minor  role.  Often  even 
in  advanced,  widespread,  and  even  markedly  active  tuberculosis 
of  the  lungs,  we  find  a  very  insignificant  involvement  of  the  peri- 
bronchial lymph  glands,  although  they  have  often  been  subject 
to  drainage  for  months  and  sometimes  for  years.  So,  in  primary 
infection  there  is  a  slight  lesion  in  the  tissues  of  the  organ  in- 
volved and  a  marked  infection  of  the  regional  glands,  while  in 
metastatic  or  secondary  lesions,  the  tissues  of  the  organs  bear  the 
brunt  of  the  infection,  while  the  glands  remain  relatively  free. 

We  see  the  same  thing  in  the  intestinal  tract.  A  secondary 
infection  in  the  intestinal  tract  may  produce  a  widespread  ul- 
ceration of  the  gut  with  very  slight  or  no  tendency  to  involve- 
ment of  the  regional  lymphatic  glands.  The  same  is  true  in  the 
larynx.  A  secondary  involvement  of  the  larynx  is  not  followed 
by  a  marked  disturbance  on  the  part  of  the  regional  lymph  glands 


84        RELATION   OF  PRIMARY  FOCUS   TO   CLINICAL   TUBERCULOSIS 

which  receive  drainage  from  it,  even  though  the  process  be  ex- 
tensive and  very  active. 

These  facts  help  to  explain  the  difference  in  the  behavior  of 
tubercle  bacilli  when  taken  into  the  body  under  different  condi- 
tions. When  an  infection  has  once  occurred,  thereafter  there  is 
an  attempt  on  the  part  of  the  tissues  to  limit  a  new  inoculation 
to  the  point  of  entry  while  a  primary  infection  is  carried  rapid- 
ly to  the  lymphatic  glands.  According  to  this  we  can  more  readily 
understand  the  tendency  which  appears  on  the  part  of  secondary 
metastases  in  the  lung  to  go  on  to  cavity  formation.  It  is  due  in 
part  to  a  sensitized  condition  of  the  cells  by  which  they  put  up  a 
specific  local  defense  and  make  an  effort  to  eliminate  the  infec- 
tion, the  same  as  the  ulceration  which  takes  place  at  the  point  of 
inoculation  in  Koch's  original  experiment:  so,  we  see  a  parallel 
in  primary  infection  of  the  lung  with  marked  secondary  involve- 
ment of  the  lymph  glands  to  the  inoculation  of  healthy  guinea 
pigs  and  the  marked  glandular  infection;  likewise  in  metastases 
in  the  lung  with  comparative  freedom  of  lymph  gland  involve- 
ment to  the  inoculation  of  the  guinea  pig  which  is  already  tuber- 
culous, where  local  ulceration  forms  and  the  lymphatics  remain 
free. 

Tuberculosis  is  Primarily  a  Lymphatic  Disease. — The  lymph 
glands  bear  such  an  important  part  in  the  primary  infection  in 
tuberculosis  that  we  are  justified  in  saying  that  tuberculosis  is 
primarily  a  disease  of  the  lymphatic  system.  Following  infection 
with  tubercle  bacilli,  the  lymphatic  glands  may  enlarge  and  be- 
come the  seat  of  active  tuberculosis;  the  disease  may  heal;  or  it 
may  remain  quiescent  without  healing.  Other  portions  of  the 
body  may  be  infected  from  this  primary  lymphatic  focus  either 
by  bacilli  passing  out  into  the  lymphatic  spaces  or  by  being  car- 
ried by  wandering  leucocytes  or,  which  is  more  common,  by  their 
passing  through  the  walls  of  blood  vessels  which  are  involved  in 
the  inflamed  tubercle.  If  the  bacilli  in  the  glands  multiply  and 
the  focus  undergoes  necrosis,  the  small  blood  vessels  adjoining  it, 
or  entering  the  tubercle,  partake  of  the  inflammation;  and,  at 
times,  bacilli  pass  through  the  vessel  walls  and  are  carried  to  dis- 
tant portions  of  the  body. 

Metastatic  Tuberculosis. — During  early  life  the  bacilli  escaping 


METASTATIC   TUBERCULOSIS  85 

from  the  lymphatic  glands  may  be  implanted  in  any  portion  of 
the  body,  organs  other  than  the  lungs  being  very  commonly  af- 
fected. In  later  life  after  adolescence,  the  lung,  particularly  the 
apex,  is  the  most  common  seat  of  metastases.  The  primary  metas- 
tases which  first  form  in  the  tissues  after  bacilli  escape  from  the 
lymphatic  glands  are,  as  a  rule,  small  and  non-virulent  in  char- 
acter. As  mentioned  elsewhere,  this  is  probably  due  to  several 
factors.  The  fact  that  bacilli  escape  into  the  blood  stream  and  are 
diluted  causes  the  infection  to  be  produced  by  few  bacilli.  While 
circulating  in  the  blood  the  bacilli  are  acted  upon  by  the  anti- 
bacillary  elements  found  therein  which  have  a  tendency  to  reduce 
their  virulence.  Aside  from  this  there  is  the  protective  influence 
of  the  cells  at  the  point  of  implantation  which  are  endowed  with 
specific  defense  and  which  must  be  overcome  before  infection  can 
take  place. 

That  this  primary  metastasis  often  heals  we  are  led  to  infer 
from  the  scars  that  are  found  in  various  portions  of  the  body, 
particularly  the  lungs,  postmortem.  Where  it  does  not  heal  it 
may  remain  quiescent  for  either  a  short  or  long  period  of  time 
and  then  take  upon  itself  activity  and  produce  clinical  symptoms. 

Whether  this  primary  metastasis  shall  be  accompanied  by  clini- 
cal symptoms  or  not  depends  upon  the  localization.  In  such  a 
delicate  tissue  as  the  meninges,  a  small  focus  is  sufficient  to  cause 
symptoms.  Likewise,  in  a  joint,  clinical  symptoms  might  be  pro- 
duced by  a  very  small  focus.  In  the  bone,  symptoms  would  prob- 
ably appear  somewhat  later.  In  the  kidney,  liver,  or  spleen,  foci 
could  exist  for  a  long  time  without  symptoms  appearing.  So 
may  they  in  the  lung. 

Relationship  of  Primary  Metastasis  to  Clinical  Tuberculosis. — 
In  order  to  understand  pulmonary  tuberculosis  as  we  find  it,  it 
is  important  to  recognize  its  relationship  to  this  primary  meta- 
static focus.  We  are  prone  to  speak  of  tuberculosis  of  the  lung 
being  typical  tuberculosis  and  speak  of  tuberculosis  of  other  or- 
gans as  being  atypical;  when,  in  reality,  we  are  probably  compar- 
ing the  primary  metastasis  in  such  tissues  as  the  meninges,  joints, 
and  glands  with  extensions  of  the  process  (secondary  metastases) 
in  the  lung.  There  are  often  years  between  the  time  of  the  forma- 
tion of  the  primary  metastasis  in  the  lung  and  the  onset  of  symp- 


86        RELATION   OF  PRIMARY  FOCUS   TO   CLINICAL   TUBERCULOSIS 

toms  of  clinical  tuberculosis,  while  in  the  more  sensitive  organs 
as  the  meninges  and  joints,  particularly,  clinical  symptoms  fol- 
low quickly  after  the  metastasis  forms,  as  previously  mentioned. 

Clinical  symptoms  do  not  appear  on  the  part  of  the  lung  until 
such  time  as  the  bacilli,  which  have  been  shut  up  in  this  primary 
metastatic  focus  begin  to  multiply  and  give  off  toxins,  which 
produce  changes  in  the  surrounding  tissues;  and,  until  bacilli 
escape  into  these  tissues,  producing  secondary  metastases.  With 
the  multiplication  of  bacilli,  toxins  are  produced  and  many  of 
the  bacilli  themselves  go  into  solution.  The  tissues  are  injured 
and  necrosis  of  tissue  often  occurs.  The  various  products  result- 
ing from  these  processes  diffuse  further  into  adjacent  tissues 
producing  more  widespread  inflammatory  change.  The  character 
and  extent  of  the  resultant  inflammation  depends  upon  the  viru- 
lence of  the  infection,  which  is  equivalent  to  saying  upon  the 
rapidity  with  which  the  bacilli  multiply  and  the  amount  of 
toxins  produced.  It  may  be  very  slight.  Under  such  conditions 
the  irritation  in  the  tissues  is  of  slight  degree.  The  tissues  are 
also  subject  to  exudation.  This  may  be  serous,  fibrinous, 
sanguinous,  cellular,  or  purulent.  Further,  the  tissues  that  are 
subject  to  this  collateral  inflammation  may  undergo  any  of  the 
changes  which  the  tubercle  bacillus  itself  may  undergo.  They 
may  be  organized  and  produce  new  tissue  or  they  may  go  on  to 
necrosis  and  destruction  of  tissue. 

The  most  serious  aspect  of  this  collateral  inflammation,  how- 
ever, is  that  it  works  injury  to  the  tissues  and  produces  a  stagna- 
tion of  lymph  and  forms  a  ready  nidus  for  further  metastases. 
Bacilli  escape  more  or  less  frequently  from  the  primary  metastasis 
into  adjoining  tissues  and  there  find  lodgment.  The  new  or  sec- 
ondary metastasis  is  very  apt  to  be  governed,  considerably,  in 
its  degree  of  virulence  by  the  original  one.  If  the  amount  of  ir- 
ritation produced  by  it  is  slight  and  the  change  in  the  tubercle 
itself  conservative,  not  only  is  the  collateral  inflammation  of  a 
mild  degree  but  few  bacilli  only  are  apt  to  find  their  way  out 
of  the  original  focus  to  establish  new  metastases.  In  this  way 
we  have  a  mild  inflammation  of  the  lung,  producing  a  fibroid  or 
indurative  form  of  tuberculosis.  On  the  other  hand,  if  the  orig- 
inal focus  is  the  seat  of  a  very  marked  activity  and  is  accom- 


SECONDARY   METASTASES   IN   THE   LUNG  87 

parried  by  severe  collateral  inflammation  more  or  less  rapid  ne- 
crosis occurs,  many  bacilli  make  their  escape  into  adjacent  tis- 
sues and  virulent  secondary  metastases  follow. 

In  pulmonary  tuberculosis  it  is  not  until  the  establishment  of 
collateral  inflammation  and  the  formation  of  secondary  metas- 
tases that  we  have  clinical  symptoms,  consequently,  what  we 
are  in  the  habit  of  diagnosing  as  early  clinical  pulmonary  tuber- 
culosis has  as  its  pathology  advanced  changes  and  the  production 
of  secondary  foci  in  the  lung. 

The  spread  of  tuberculosis  in  the  lung  is  favored  by  necrosis 
and  caseation  of  tubercles  permitting  bacilli  to  escape  from  their 
original  focus,  by  the  injury  of  the  surrounding  tissue  which  is 
produced  by  the  diffusion  of  toxins  with  their  accompanying 
exudative  inflammation;  and,  by  conditions  which  favor  implan- 
tation of  bacilli.  Necrosis  is  not  necessary,  however,  for  a  wide- 
spread chronic  indurative  tuberculosis  is  often  found  without 
necrosis  having  taken  place. 

Implantation  of  bacilli,  which  escape  into  adjacent  lymph 
spaces,  is  favored  by  lack  of  motion  on  the  part  of  the  pulmon- 
ary tissue,  while  the  implantation  of  those  which  escape  into  the 
bronchi  is  favored  by  motion  or  coughing. 

The  primary  metastasis  in  tuberculosis  of  the  lung  in  the  adult 
is  nearly  always  near  the  apex.  From  there  the  disease  extends 
toward  the  base  either  through  adjacent  lymph  spaces  or  through 
infection  carried  by  way  of  the  bronchi.  In  the  latter  instance 
sometimes  a  medium  size  bronchus  will  be  plugged  with  mucous 
and  the  entire  area  supplied  by  it  be  involved  in  a  secondary  in- 
fection. 

The  importance  of  previous  glandular  infection  in  its  suggested 
relationship  to  adult  tuberculosis  is  borne  out  by  the  report  of 
Monckeberg,1  who  reports  postmortems  made  on  soldiers  dying 
from  acute  diseases  and  injuries  received  in  battle  in  whom  both 
active  and  quiescent  lesions  were  found. 

In  85  bodies  examined,  tuberculosis  was  found  27  times,  or  in 
31.76  per  cent.  He  included  as  tuberculosis  only  cases  where 
definite  macroscopic  induration  was  found  and  excluded  all  scars 

1Professor  G.  Monckeberg:  Tuberkulose  Befunde  bei  Obductionen  von  Kombattanten, 
Zeitschrift    fur    Tuberkulose,    Bd.    24,    Heft    1,    1915. 


88        RELATION   OF   PRIMARY   FOCUS   TO   CLINICAL  TUBERCULOSIS 

which  might  be  questionable  or  which  might  prove  to  be  tuber- 
culosis upon  microscopic  search. 

These  soldiers  were  strong,  healthy  men,  capable  of  enduring 
the  hardships  of  war.  They  were  between  the  ages  of  twenty-one 
and  forty-three.  Tuberculosis  had  not  been  suspected  prior  to 
their  taking  up  active  duty  or  they  would  have  been  excluded. 

Tuberculosis  was  the  cause  of  death  in  five  cases.  It  is  prob- 
able that  the  activity  which  went  on  to  the  death  of  the  patient 
was  due  to  lowered  resistance  incident  to  the  strain  of  service. 
In  twenty-two  cases  the  tuberculosis  was  not  suspected  until 
found  postmortem,  although  the  process  was  active  in  three  of 
these  cases.  In  nineteen  the  process  was  quiescent.  The  localiza- 
tion of  the  lesions  is  interesting  and  shown  in  the  table  below. 
It  is  interesting  to  speculate  on  how  many  more  of  these  foci 
would  have  been  active  had  the  men  been  subjected  to  longer 
strain. 

Localization  of  Unsuspected  Tuberculous  Lesions  in 
Nineteen  Bodies  of  Soldiers. 

Induration  in  both  apices 3  cases 

Induration  in  the  right  apex 1  case 

Induration  in  the  right  lower  lobe 1  case 

Caseation  or  calcification  of  bronchial  gland  (left) 1  case 

Caseation  or  calcification  of  bronchial  gland  (right) 9  cases 

(One  of  these  cases  also  had  areas  in  both  apices) 

Caseation  and  calcification  of  bifurcation  glands 2  cases 

(One   of  these   also   had  calcification  of   the  bronchial 
glands  on  the  right) 

Caseation  and  calcification  of  the  glands    of  the  mesentery. .  4  cases 

Leschke2  calls  attention  to  the  marked  increase  in  tuberculosis 
in  the  army  during  the  present  war  as  compared  with  the  very  low 
morbidity  found  in  times  of  peace.  During  active  service  tuber- 
culosis has  increased  markedly.  He  attributes  this  difference 
to  the  strain  incident  to  the  changed  condition  of  life  and  draws 
the  conclusion  which  seems  but  natural,  that  this  fact  of  itself 
is  strong  evidence  in  favor  of  the  theory  that  active  adult  tuber- 
culosis is  an  extension  from  an  already  existing  focus,  most 
probably  such  as  are  found  in  the  body  in  childhood. 

2E.  Leschke:  Die  Tuberkulose  im  Kriege,  Munchener  Medicinsche  Wochenschrift, 
1915,  No.   11,  p.   363. 


INFECTIONS   FROM    WITHOUT   IN   LATER   LIFE  89 

Infections  From  Without  in  Later  Life. — While  we  cannot 
deny  the  possibility  of  infections  occurring  from  without  the 
body  in  later  life,  yet,  according  to  our  newer  knowledge,  we 
must  recognize  that  such  infections  are  probably  comparative- 
ly rare.  The  early  period  of  life,  with  its  absence  of  specific  cell 
defense,  offers  a  fairly  easy  entrance  for  bacilli,  while  the  period 
after  this  specific  defense  has  been  established  is  one  of  increased 
resistance.  While  bacilli,  entering  the  body  as  they  do  for  the 
most  part  in  small  numbers,  may  pass  through  the  mucous  mem- 
branes and  be  destroyed,  without  infection  occurring;  yet,  now 
and  then,  larger  numbers  enter;  and  these,  escaping  the  action 
of  the  general  agencies  of  defense,  find  a  nidus  in  the  lymph 
glands  and  produce  a  tuberculous  focus.  This  destruction  of 
bacilli  in  early  life  within  the  body,  as  well  as  this  early  focus 
of  infection,  creates  the  specific  cell  defense  which  offers  a  bar- 
rier to  the  future  entrance  of  bacilli  into  the  body.  This  specific 
defense  is  probably  a  general  property  of  body  cells,  as  evidenced 
by  the  fact  that  all  tested  body  cells,  whether  of  the  skin  or 
mucous  membranes,  respond  with  a  reaction  to  tuberculin;  and 
tuberculous  foci,  wherever  found,  show  the  focal  reaction  to  the 
specific  bacillary  products. 

The  effect  of  this  defense  is  to  ward  off  bacilli  and  make  their 
implantation  difficult  or  impossible.  To  what  extent  it  is  ef- 
fective may  be  judged  by  the  illustration  furnished  by  advanced 
tuberculosis,  which  I  have  mentioned  so  often.  While  a  few 
bacilli  passing  over  a  mucous  membrane  gain  entrance  and  cause 
infection  in  the  non-tuberculous,  millions  may  pass  over  the 
mucous  membranes  daily,  after  infection  has  occurred  and  a 
specific  defense  has  been  developed  on  the  part  of  the  cells,  with- 
out implantation  occurring.  This  defense  offered  by  the  cells 
of  the  air  passage  and  intestinal  tract,  demonstrates  that,  for  an 
infection  to  occur,  in  one  who  has  developed  immunity  from  a 
previous  tuberculous  focus,  it  is  necessary  that  conditions  for 
implantation  must  be  extremely  favorable.  The  quantity  of 
bacilli  must  be  large,  they  must  be  held  in  contact  with  the  tis- 
sues for  a  sufficient  time,  or  the  cellular  defense  must  be  reduced 
or  in  abeyance. 


90        RELATION   OP  PRIMARY  FOCUS   TO   CLINICAL    TUBERCULOSIS 

We  do  not  know  much  about  the  disappearance  or  reduction  of 
specific  defense  in  actual  life,  but  we  assume  that  it  is  subject 
to  great  variation.  Immunity  to  tuberculosis,  as  far  as  we  know, 
is  relative ;  and  we  believe  that  it  is  impossible  to  develop  it  to 
so  high  a  degree  that  it  cannot  be  overcome  in  case  bacilli  should 
gain  access  to  the  tissues  in  sufficient  numbers  and  be  held 
in  situ  sufficiently  long. 

It  can  readily  be  seen  that  an  entrance  through  mucous  mem- 
branes, such  as  occurs  in  the  natural  course  of  life,  and  which  is 
so  common  during  the  early  years,  where  bacilli  enter  the  body 
through  air  or  food,  would  not  be  easy  of  accomplishment  after 
the  cells  have  been  endowed  with  specific  protective  powers,  and, 
could  probably  take  place  only  in  case  the  bacilli  were  aided  in 
some  such  manner  as  by  collecting  at  some  point  on  the  mucous 
membrane  and  remaining  in  contact  for  a  period  sufficiently  long 
for  the  local  defense  to  be  overcome  to  such  an  extent  that  the 
mucous  membrane  becomes  penetrated.  That  this  element  of 
time  contact  is  important,  is  suggested  by  the  surface  infections 
which  we  find  as  complications  in  advanced  tuberculosis.  Bacil- 
lus bearing  sputum  passes  from  the  ulceration  in  the  apex  of  the 
lung  and  does  not  produce  infection  along  its  path  until  it  reaches 
the  larynx,  unless  through  aspiration  a  bronchus  is  plugged  and 
the  sputum  is  kept  in  close  contact  long  enough  for  implantation 
to  occur.  The  larynx  offers  excellent  opportunity  for  implan- 
tation because  of  the  fact  that  the  secretions  collect  in  passing 
the  chink ;  yet,  in  spite  of  this  splendid  opportunity,  quite  a  pro- 
portion of  patients  will  go  down  to  death  from  pulmonary  tuber- 
culosis without  laryngeal  infections  occurring.  The  same  is  true 
of  the  intestinal  tract.  Infection  is  most  apt  to  occur  in  the  low- 
er end  of  the  ileum  and  the  cecum  and  ascending  colon  where 
retardation  of  the  contents  occurs. 

This  evidence  goes  to  show  that  if  our  specific  defense  is  well 
developed,  surface  infection  is  not  easy  of  accomplishment.  Con- 
sequently, the  conclusion  may  be  drawn  that  infection  through 
the  ordinary  paths  which  succeed  in  causing  implantations  in  the 
child  is  accomplished  with  difficulty  in  the  adult  as  long  as  he 
is  protected  by  the  cellular  defense  which  results  from  his  early 
infection;  and  that  adult  infections,  from  without,  are  probably 


METASTASES  PROM  WITHIN  EASY  91 

confined  to  those  individuals  who  have  escaped  infection  in 
earlier  life,  if  there  be  such;  or  those  in  whom  the  specific  de- 
fense has  gradually  disappeared;  or  to  instances  where  bacilli 
are  brought  in  contact  with  the  mucous  membranes  from  without 
in  large  numbers  and  kept  in  contact  for  a  time  sufficiently  long 
for  infection  to  occur. 

The  conditions  surrounding  metastases  which  take  place  from 
the  focus  within  are  different.  Here  the  bacilli  are  already  within 
the  tissues.  When  they  make  their  escape  it  is  into  the  lymph 
channels  or  blood  stream,  consequently,  if  they  are  permitted 
to  remain  in  situ  in  any  part  of  the  body  long  enough  they  have 
exceptional  opportunity  for  causing  infection.  We  are  probably 
warranted,  however,  in  assuming  that  there  are  many  instances 
of  bacilli  gaining  access  to  the  lymph  and  blood  stream  for  every 
infection  which  occurs.  The  fact  that  these  secondary  metastases 
are  usually  of  low  virulence  and  the  lesion  fibroid  in  form  at 
first,  shows  the  influence  of  the  specific  defense  upon  the  micro- 
organisms. These  secondary  metastases  are  formed  with  difficulty 
and  require  special  anatomical  conditions  which  favor  the  re- 
tention of  bacilli  in  situ  for  implantation  to  occur.  When  we 
consider  the  relative  ease  for  such  implantation  to  occur  through 
the  lymph  and  blood  streams  and  the  relative  difficulty  of  en- 
trance through  the  surface  of  the  mucous  membranes,  and  con- 
sider that  the  nidus  from  which  the  bacilli  may  come  is  present 
in  so  large  a  number  of  adults  as  a  remnant  of  their  early  child- 
hood infection,  we  are  justified  in  considering  that  the  tuber- 
culous disease  in  the  adult  is  most  probably,  largely,  a  result  of 
an  infection  from  within  the  patient's  own  body,  and  not  a  new 
implantation  of  bacilli  from  without. 

The  fact  that  infection  often  occurs  in  several  members  of  the 
same  family,  one  after  the  other,  or  at  the  same  time,  is  brought 
forth  as  an  argument  against  this,  and  as  proving  an  infection 
immediately  prior  to  the  development  of  the  clinical  disease.  But 
this  is  just  as  likely  due  to  the  fact  that  all  were  subjected  to 
the  same  early  infections  and  the  same  influences  which  tended  to 
lower  resistance  and  favor  activity.  Where  one  clinical  case  fol- 
lows another,  the  depression  caused  by  the  disease  in  another 
member  of  the  family,  or  the  deprivations  caused  by  the  extra 


92        RELATION   OF  PRIMARY  FOCUS   TO   CLINICAL  TUBERCULOSIS 

tax  upon  the  family's  resources,  are  undoubtedly  factors.  This 
factor  of  extra  strain  is  shown  in  the  case  of  the  soldiers  above 
mentioned. 

The  size  of  the  early  infection  is  also  very  important.  All  else 
being  equal,  the  larger  the  early  lesion,  the  greater  the  danger 
of  future  active  disease.  This  explains  why  so  many  cases  of 
active  tuberculosis  occur  in  families  where  open  tuberculosis 
existed  during  the  children's  early  years.  The  intimate,  pro- 
longed association  provides  the  opportunity  for  massive  infec- 
tion. 

This  question  has  an  extremely  practical  bearing  in  the  pre- 
vention of  the  spread  of  tuberculosis.  It  shows  that  children 
should  be  shielded  as  much  as  possible  from  infection,  particular- 
ly massive  infection,  if  we  would  limit  active  tuberculosis  in  the 
adult.  It  further  suggests  that  there  is  no  danger  in  a  casual  asso- 
ciation with  the  tuberculous;  and  that,  where  proper  care  is 
used  for  the  destruction  of  bacillus-bearing  discharges,  and  proper 
hygienic  conditions  are  maintained,  even  a  prolonged  association 
on  the  part  of  those  who  have  developed  their  specific  cellular  de- 
fense, is  without  danger.  This  is  borne  out  by  the  experience  of 
sanatoria.  I  have  not  had  a  single  instance  of  direct  infection 
of  employees  and  attendants  in  sanatoria  brought  to  my  attention. 
This  is  extremely  important  because  of  its  influence  on  the  future 
hospital  status  of  tuberculous  patients.  Phthisiophobia  has  been 
so  thoroughly  inoculated  in  the  mind  that  in  some  quarters  tu- 
berculous patients  have  been  wrongly  refused  entrance  to  hospi- 
tals lest  they  should  infect  other  inmates. 


Fig.    13. — Showing  the  course  of  the  lymphatics   from   the  tonsillar   region  into  the   deep 

cervical  glands.     (Most.) 


CHAPTER  IV. 
TUBERCULOSIS  IN  CHILDHOOD. 

The  Natural  Defense  of  the  Little  Child. — Precedent  to  a  dis- 
cussion of  tuberculosis  in  childhood,  it  is  well  to  consider  the 
natural  protective  mechanism  of  the  child  which  prevents  it  from 
being  destroyed  by  the  invading  bacillus  before  it  develops  an  im- 
munity or  specific  resistance  against  it. 

The  natural  defense  is  both  humeral  and  cellular.  The  cells 
which  take  part  in  the  destruction  of  invading  microorganisms 
belong  to  various  classes.  This  function  is  possessed  by  the  en- 
dothelial and  connective  tissue  cells,  but  is  strongest  in  the  leuco- 
cytes, and  particularly  the  lymphocytes. 

Of  all  structures  and  systems  of  the  body  the  lymphatic  sys- 
tem plays  the  greatest  protective  role.  In  fact,  it  is  upon  this 
system  that  the  child  depends  almost  wholly  for  his  protection 
during  his  early  years.  It  is  during  this  period  also  that  the 
lymphatic  system  is  most  active. 

In  early  childhood  the  lymphatic  tissue  is  prominent.  An 
abundance  of  it  is  placed  as  an  outer  defense  to  guard  the  vul- 
nerable points  of  the  body  such  as  the  vault  of  the  pharynx  which 
meets  bacteria  which  are  taken  in  through  inhalation;  the  root 
of  the  tongue  and  sides  of  the  fauces  which  are  particularly  ex- 
posed to  the  bacteria  which  enter  the  body  by  way  of  the  mouth ; 
and  in  the  lower  ileum  which  is  particularly  exposed  to  infec- 
tion by  the  bacteria  which  have  been  ingested,  because  of  the 
fact  that  this  is  a  point  of  stagnation  of  intestinal  contents  and 
rapid  absorption. 

In  case  bacteria  pass  these  outer  defenses,  a  second  line  of  de- 
fense is  arranged  in  the  lymphatic  glands  which  are  so  situated 
that  they  receive  drainage  from  every  tissue  of  the  body;  and 
which  are  located  in  great  abundance  near  the  specially  exposed 
surfaces  as  exemplified  in  the  cervical,  mediastinal,  and  mesen- 
teric glands.     These  masses  of  lymphatic  tissue,  represented  by 


94  TUBERCULOSIS  IN   CHILDHOOD 

the  pharyngeal,  lingual  and  faucial  tonsils  and  by  Pyer's  patches 
as  well  as  the  lymphatic  glands  have  the  special  function  of  form- 
ing lymphocytes  and  are  better  provided  with  the  cells  upon 
which  the  little  child  must  depend  for  his  protection,  than  any 
other  tissue  of  the  body. 

As  the  child  grows  older  and  his  body  cells,  generally,  take 
upon  themselves  the  function  of  producing  specific  proteolytic 
enzymes  for  his  protection,  the  lymphatic  protection  which  has 
served  him  during  his  early  years  is  no  longer  so  necessary,  con- 
sequently the  lymphatic  tissue  atrophies. 

The  importance  of  the  lymphatic  tissue  in  the  protection  of  the 
little  child  should  be  appreciated.  The  part  played  by  the  ton- 
sillar tissue  in  Waldeyer's  ring  in  warding  off  infection  or  fail- 
ing this,  in  receiving  the  infectious  microorganisms  into  tissue 
which  is  best  prepared  for  limiting  their  action,  should  be  em- 
phasized. The  tonsillar  tissue  should  not  be  sacrificed  unneces- 
sarily, and  it  should  be  the  aim  of  the  physician  to  save  its  pro- 
tective function  to  the  child  until  he  has  come  in  contact  with 
bacilli  and  other  microorganisms  in  sufficient  numbers  to  cause 
his  cells  generally  to  take  upon  themselves  the  function  of  pro- 
ducing specific  defensive  enzymes.  After  that  has  taken  place, 
lymphatic  protection  assumes  a  secondary  role,  and  the  tonsillar 
tissue  is  not  so  necessary.  Figs.  13  and  14  show  the  natural  drain- 
age of  the  tissues  of  the  tonsils  and  oropharynx  into  the  deep 
cervical  lymphatic  glands  and  Fig.  15  shows  the  peribronchial 
and  peritracheal  glands  in  their  relation  to  the  bifurcation  of  the 
trachea. 

Tonsillar  tissue  which  is  the  seat  of  dangerous  focal  infections , 
or  which  is  interfering  with  the  drainage  of  the  nasal  cavities, 
or  threatening  the  integrity  of  the  ear ,  or  in  other  ways  threat- 
ening harm  will  have  to  be  sacrificed.  Where  no  such  cause  for 
removal  exists,  however,  the  child  should  be  given  the  benefit  of 
their  protection  during  his  earliest  years.  They  should  not  be 
sacrificed  uselessly,  as  though  they  were  of  no  value. 

Infection  and  Immunity. — Tuberculosis  is  primarily  an  infec- 
tion of  childhood.  According  to  our  conception,  the  struggle  be- 
tween the  child  and  the  tubercle  bacillus  begins  practically  at 
birth,  although  the  first  two  years  show  comparatively  little  in- 


Fig.  14. — Showing  the  drainage  from  the  oropharynx  into  the  deep  cervical  glands.     (Most) 


LYMPHATIC   DEFENSE    OF    THE    CHILD 


95 


fection.  This  struggle  goes  on  until  the  resisting  power  of  near- 
ly every  child  is  overcome  by  the  tubercle  bacillus  to  the  extent 
that  infection  is  established. 

Coincident  with  infection  goes  another  process,  that  of  the  pro- 
duction of  specific  immunity.  The  child  takes  a  few  bacilli  into 
the  body  and  they  are  destroyed.  Being  destroyed  their  bodies 
go  into  solution.  The  specific  products  derived  from  the  bodies 
of  the  tubercle  bacillus  are  set  free.     Specific  products  are  also 


Fig.  15. — Showing  the  peribronchial  and  peritracheal  glands.     (Sukiennikow.) 

given  out  into  the  tissues  from  the  focus  of  infection  when  it  has 
been  established.  These  bacillary  substances  stimulate  the  body 
cells  and  make  them  sensitive  to  further  inoculations  with  tuber- 
cle bacilli  or  their  products  and  cause  them  to  produce  specific 
protective  enzymes  which  both  remain  attached  to  the  cells  and 
are  cast  off  into  the  circulation.  The  result  is  that  in  this  way  a 
gradually  increasing,  specific  resisting  power  is  built  up  and  af- 


96  TUBERCULOSIS  IN   CHILDHOOD 

ter  a  while  the  individual  reaches  a  condition  in  which  he  is  able 
to  withstand  large  doses  of  tubercle  bacilli. 

In  this  connection  the  animal  experiments  of  Webb  and  Wil- 
liams1 are  extremely  interesting.  By  the  systematic  inoculation 
of  guinea  pigs  with  increasing  numbers  of  tubercle  bacilli  Webb 
has  been  able  to  produce  such  a  state  of  immunity  in  the  animal 
that  it  is  capable  of  withstanding  as  much  as  150,000  tubercle 
bacilli  at  a  single  inoculation  without  infection  occurring. 

In  speaking  of  immunity  in  tuberculosis  we  must  bear  in  mind 
that  we  are  speaking  of  a  relative  immunity,  not  an  absolute  one. 
While  these  infections  produce  sufficient  protection  to  overcome 
ordinary  inoculations  of  tubercle  bacilli,  yet  it  is  probable  that 
no  individual  is  absolutely  protected  from  further  infection.  If 
the  inoculation  consists  of  a  sufficient  number  of  tubercle  bacilli, 
or  if  repeated  inoculations,  sufficiently  large,  take  place,  a  new 
infection  will  most  likely  result. 

The  Difference  in  the  Tuberculous  Process  at  Different  Age 
Periods. — When  the  child  is  born  he  has  within  his  body  sub- 
stances and  tissues  which  protect  him  against  various  infections. 
We  must  look  upon  these  as  being  of  a  general  instead  of 
specific  nature  and  not  affording  a  high  degree  of  protection  yet 
sufficient  to  protect  against  repeated  inoculations  of  small  num- 
bers of  bacteria.  Sooner  or  later,  however,  this  natural  defense 
is  broken  down  and  the  child  becomes  infected  with  disease  organ- 
isms of  various  kinds.  Nearly  every  child  will  eventually  have 
one  or  more  of  the  common  infections  of  childhood.  When  the 
child's  tissues  come  in  contact  with  specific  microorganisms,  as 
occurs  when  they  are  taken  into  the  body  or  when  it  overcomes 
an  infection,  there  is  built  up  within  his  body  a  specific  defense, 
a  specific  immunity  against  the  organism  which  produces  that 
particular  disease.  In  tuberculosis,  the  child  gradually  develops 
a  specific  resisting  power  to  tubercle  bacilli  as  mentioned  above. 
This  immunity  attains  such  a  high  degree  in  advanced  tubercu- 
losis, particularly  in  adult  life,  that  an  individual  may  have  mil- 
lions of  bacilli  within  his  body  and  may  be  pouring  them  out 
in  great  numbers  through  the  air  passages ;  or,  after  swallowing 
them,  they  may  pass  through  the  intestinal  tract,  and  yet  his 


2VI    International    Congress    on    Tuberculosis,    vol.    i,    part    1,    p.    174. 


LACK  OF  SPECIFIC  DEFENSE  IN  EARLY  YEARS 


97 


specific  resistance  may  prevent  implantation  from  taking  place 
as  previously  mentioned. 

Owing  to  the  fact  that  there  is  very  little  specific  immunity  or 
resistance  against  tubercle  bacilli  during  the  first  years  of  life, 
if  an  infection  occurs  at  this  time,  it  is  very  apt  to  be  severe  in 
character  and  usually  fatal. 

This  is  shown  well  in  statistics  arranged  in  Table  I  from 
Hamburger:2 

TABLE  I. 


Mortality  of  Tube 

RCULOSIS 

by  Age  Periods 

I 

II 

III 

IV 

V 

VI 

1    YEAR 

2 

YEARS 

3  to  4 

YEARS 

5  to  6 

YEARS 

7  to  10 

YEARS 

lltol4 

0  to  3 
months 

4  to  6 
months 

7  to  12 
months 

YEARS 

Number  of  cases.  . 

4 

49 
13 

32 

'   74 

102 

38 

41 

31 

4 

44 
13 

27 

51 

69 

23 

28 

16 

Percentage  of 
fatality 

100% 

90% 
100% 

80% 

70% 

67% 

60% 

68% 

50% 

From  this  it  will  be  seen  that  during  the  first  year  of  life 
nearly  90  per  cent  of  the  cases  of  tuberculosis  are  fatal  while 
at  the  age  period  of  11  to  14  years  such  a  degree  of  resistance 
has  been  attained  that  only  50  per  cent  are  fatal. 

Hamburger  also  examined  these  patients  with  reference  to 
signs  of  healing,  the  results  of  which  are  set  forth  in  Table  II. 


TABLE  II. 


Frequency  of  Healed  Tuberculosis  by  Age  Periods 


1 

YEAR 

2 

YEARS 

3  to  4 

YEARS 

5  to  6 

YEARS 

7  to  10 

YEARS 

11  to  14 

YEARS 

Total  number  of  cases 

Number  with  signs  of  healing 

Percentage  showing  healing 

49 
0 
0 

74 
0 
0 

102 

7 
7 

38 

4 
10 

41 

7 
17 

31 

10 
33 

2Kindertuberkulose,   Leipzig  and  Wien,    1910. 


98 


TUBERCULOSIS   IN    CHILDHOOD 


From  Table  II  it  is  seen  that  during  the  first  and  second  years 
of  life  there  are  no  signs  of  healing  present.  During  the  third 
and  fourth  years  signs  of  healing  appear  in  7  per  cent;  during 
the  fifth  year  in  10  per  cent ;  from  the  seventh  to  the  tenth  year 
17  per  cent;  and,  from  the  eleventh  to  the  fourteenth  year,  33 
per  cent.  This  is  explained  by  the  fact  that  the  child  is  gradually 
developing  a  greater  specific  immunity,  although  there  are  prob- 
ably other  elements  which  enter  and  should  be  considered.  Not 
only  is  there  a  difference  in  mortality  from  tuberculosis  during 
the  early  and  late  periods  of  childhood,  but  there  is  also  a  great 
difference  in  its  localization,  as  will  be  seen  from  Table  III, 
taken  from  Newsholme:3 

TABLE  III. 


Death  Rate  from  Tuberculosis  per  100,000  Persons  Living  at 
Each  Age  Period 

0-5 

5-10 

10-15 

15-20 

20  AND  UPWARDS 

Pulmonary  tuberculosis 

31 
109 
125 

20 

27 
10 

41 
12 

7 

90 
6 
5 

176 
2 
3 

The  statistics  shown  for  England  and  Wales  in  Table  III  are 
somewhat  different  from  those  on  the  Continent  in  that  the  per- 
cent age  of  tabes  mesenterica  is  more  common  in  England  and 
Wales  than  it  is  on  the  Continent.  It  will  be  noted  that  the  early 
years  are  those  of  non-pulmonary  involvement,  while  the  later 
ones  are  almost  wholly  pulmonary.  We  must  conceive  of  the  child 
as  lacking  in  specific  defense ;  so  there  is  nothing  to  limit  infection 
when  bacilli  gain  access  to  the  tissues  except  the  natural  elements. 
As  a  result,  the  bacilli,  if  not  destroyed,  scatter  more  widely  than 
they  do  in  adults,  affecting  many  organs. 

Further  emphasizing  the  frequency  of  non-pulmonary  tuber- 
culosis in  young  children  I  desire  to  call  attention  to  Table  IV 
from  Hamburger.  In  110  children  with  fatal  tuberculosis,  the 
death  in  eighty  cases  was  caused  by  miliary  and  meningeal  tuber- 
culosis, while  in  only  thirty  was  it  due  to  chronic,  general  or  pul- 
monary tuberculosis. 


sThe    Prevention    of    Tuberculosis,    2nd    ed.,    London,    1910. 


FACTORS  PREDISPOSING   TO  INFECTION 


99 


TABLE  IV. 


Relative  Frequency  of  Active  and  Chronic  Tuberculous  by  Age  Periods 


I 

II 

III 

IV 

V 

VI 

CAUSE    OF    DEATH 

1 

YEAR 

2 

YEARS 

3  to  4 

YEARS 

5  to  6 

YEARS 

7  to  10 

YEARS 

11  to  14 

YEARS 

Miliary     and   meningeal  tubercu- 

13 

19 

28 

10 

8 

f  2 

Chronic  and  general  or  pulmonary 
tuberculosis 

7 

6 

6 

1 

4 

6 

20 

25 

34 

11 

12 

8 

In  Chapter  V,  page  124,  I  have  offered  an  explanation  for  the 
fact  that  tuberculosis  in  childhood  may  involve  organs  other  than 
those  of  the  lung  as  readily  as  the  lung  itself,  and,  in  case  the 
lung  is  involved,  the  infection  may  be  in  other  portions  than  the 
apex,  and  will  not  discuss  it  here. 

What  Predisposes  a  Child  to  Infection. — The  most  striking  fact 
which  is  forced  upon  us  when  we  consider  the  amount  of  tuber- 
culosis present  in  childhood  is  that  the  opportunity  for  infec- 
tion is  almost  universal.  One  person  in  every  nine  or  ten  dies  of 
tuberculosis  and  there  are  about  four  persons  ill  of  it  for  every- 
one who  dies.  Every  person  who  dies  of  it  is  ill  and  expectorat- 
ing bacilli  on  an  average  of  three  or  four  years  before  death. 
Among  the  poor  where  families  are  large  and  people  are  crowded 
together  and  obliged  to  live  under  unsanitary  conditions,  there 
is  probably  ten  times  as  much  tuberculosis  as  there  is  among  the 
well  to  do;  and  the  poor  are  the  people  who  are  most  careless 
of  their  expectoration  and  consequently  most  dangerous  to  their 
fellows.  Under  these  circumstances  we  are  confronted  by  a  situa- 
tion which  offers  an  almost  unlimited  opportunity  for  infection. 
Contamination  through  milk ;  through  articles  of  food ;  merchan- 
dise, through  the  habits  of  children  crawling  on  the  floor  and 
putting  their  hands  from  the  floor  to  their  mouths,  likewise  the 
habit  of  children  putting  things  in  their  mouths  and  trading 
toys  which  have  been  used  by  others;  and  the  possibility  of  in- 
fection through  flies,  are  all  means  by  which  the  bacillus  is 
brought  into  the  body  of  the  child  (see  Chapter  II). 


100  TUBERCULOSIS  IN   CHILDHOOD 

The  fact  that  there  is  a  lack  of  specific  resistance  in  the  small 
child  is  also  extremely  important.  Aside  from  this  we  have  the 
peculiar  structures  of  the  children  which  are  apparently  less  re- 
sistant to  infection  than  those  of  the  adult.  Behring  has  shown 
that  the  mucous  membrane  of  the  intestine  in  a  small  child  offers 
little  or  no  protection  against  infection.  Cornet4  states  that 
in  making  several  hundred  animal  experiments  he  has  come  to 
the  conclusion  that  the  mucous  membranes  are  more  easily  pene- 
trated in  young  animals  than  in  adult  animals  and  he  thinks 
that  the  reason  the  infection  is  carried  to  the  lymph  glands  in 
the  young  is  because  of  the  wider  lymph  spaces  as  compared 
with  those  of  the  adult.  The  absence  of  specific  cellular  de- 
fense in  early  years  is  probably  more  of  a  factor  than  the 
ease  with  which  mucous  membranes  are  penetrated.  It  is  prob- 
able that  the  lymphatic  system  affords  the  greatest  natural  pro- 
tection of  the  child  against  bacteria,  and  that  the  child's  de- 
fense depends  almost  wholly  upon  it  until  such  a  time  as  a  spe- 
cific resistance  has  been  developed  through  contact  with  specific 
microorganisms. 

Frequency  of  Tuberculosis  in  Children. — When  the  importance 
of  the  various  tuberculin  tests,  particularly  the  cutaneous,  in- 
tradermal and  needle  track  reactions  came  to  be  understood,  their 
ease  of  application  gave  us  a  new  method  of  studying  the  in- 
cidence of  tuberculosis  in  childhood  and  we  were  greatly  aston- 
ished to  find  how  common  tuberculous  infection  really  is. 

Postmortem  examinations  in  children  have  for  a  long  time 
shown  tuberculosis  to  be  very  prevalent,  but  they  have  not  been 
made  with  sufficient  care  to  show  how  high  this  percentage  really 
is.  Those,  however,  which  have  been  made  since  the  universality 
of  the  disease  has  been  revealed  by  the  tuberculin  tests  have 
come  nearer  to  approaching  the  pathological  statistics. 

The  tuberculin  test  has  been  administered  to  many  groups  of 
children  by  different  observers  in  all  sections  of  the  world,  all 
of  whom  have  come  to  about  the  same  conclusion.  The  follow- 
ing tables  will  graphically  show  how  common  infection  is,  ac- 
cording to  various  age  periods.     Table  V  is  from  Hamburger5 


*Die  Tuberkulose,  1st  ed.,  Alfred  Holden,  Wien,  1899. 
"Kindertuberkulose,  Leipzig  and  Wien,  1910. 


INCIDENCE  OF  INFECTION 


101 


TABLE  V. 


Percentage  op  Children  Reacting  to  Tuberculin  According  to  Age  Period. 
Test  Repeated  When  Negative  (Vienna). 


46  children  in  t 

ie    2nd  year  of  whom      4 

or 

9  per  cent  reac 

56         < 

t       it    i 

i      3rd     it     n 

"         11 

<  t 

20    "     "         " 

75         ' 

t       ttt 

i      4th     it     it 

"         24 

1 1 

32    "     "         " 

50         ' 

t         tit 

'      5th     "     " 

"         26 

tt 

52    "     "         " 

63         ' 

t         ttt 

'      6th     "     " 

"         32 

it 

51    "     "         " 

46         ' 

i         tit 

t      7th     it     it 

"         28 

it 

61    "     " 

30         ' 

t         tit 

1      8th     "     " 

"         22 

it 

73    it      it          tt 

35         ' 

t         ttt 

'      9th     "     " 

"         25 

1 1 

71    "      "          " 

26         ' 

t         ttt 

'    10th     "     " 

"         22 

1 1 

85    "     "         " 

29         ' 

t         tit 

'    11th     "     " 

"         27 

tt 

93    "     "         " 

19         ' 

t         ttt 

1    12th     "     " 

"          18 

1 1 

95    "     "         " 

17         ' 

t         ttt 

'    13th     "     " 

"          16 

it 

94    "     "         " 

17         < 

t         tit 

'    14th     "     " 

"         16 

tt 

94    "     "         " 

509 


271 


TABLE  VI. 


Percentage  of  Children  Showing  Tuberculous  Infection  on  Postmortem 

Examination 


AGE 

NUMBER 
OF  THOSE 
EXAMINED 

FREE 
FROM 
TUBER- 
CULOSIS 

INFECTED 
WITH 
TUBER- 
CULOSIS 

DIED  OF 
TUBER- 
CULOSIS 

LATENT 
TUBER- 
CULOSIS 

LATENT 
TUBERCLE 
BACILLI 

1st  yr 

2  yea 
3 

[1st  quarter. . 

J  2d  quarter.  . 

'13d  quarter.  . 

[4th  quarter.. 

82 

55 
36 

28 

201 
65 
26 
18 
16 
12 
13 
20 
9 
11 
14 
13 
13 
13 
40 

% 

76 
46 
20 

19 80 

161 

48       74 

18       69 

12       67 

7       44 

2  20 
7       54 

7  35 

3  33 

3  27 
1         7 

4  31 
4       31 
1          8 

8  20 

% 

6 

9 
16 

9—  20 
40 
17       26 

8  31 
6       33 

9  56 
10       80 

6       46 

13       65 

6       67 

8  73 
13       93 

9  69 
9       69 

12       92 
32       80 

4 

4 
10 

6— 
24 
14 

4 

5 

8 

8 

3 

6 

3 

4 

7 

6 

4 

4 
19 

1 

2— 
3 
1 
1 
1 

i 

*6 

2 

4 

4 

3 

5 

8 
13 

2 
5 
5 

1— 
13 
2 

3 

4 

5 

i 

6 

l 

7       ' 

2 

8 

1 

9 

1 

10 

11 

2 

12       ' 

13       ' 

14       ' 

15 

484 

286       59 

198       41 

119 

52 

27 

484 

198 

102 


TUBERCULOSIS  IN   CHILDHOOD 


and  is  based  upon  the  positive  reaction  to  the  tuberculin  tests.  A 
failure  to  react  to  one  test  was  not  taken  as  negative,  but  the 
same  test  was  repeated  or  another  employed,  before  an  opinion 
was  given. 

Table  VI,  shown  on  page  101,  based  on  postmortem  examinations 
is  from  Harbitz.6 

Tables  VII  and  VIII  from  Fishberg7  show  the  ages  of  the 
children  and  the  number  and  proportion  giving  positive  or  nega- 
tive reactions.  These  represent  children  in  the  dispensary  who 
were  given  only  a  single  test.     The  proportion  of  positive  re- 

TABLE  VII. 


Percentage  of  Children  Reacting  to  Tuberculin  Test,  Administered 
Once  (New  York) 


positive 

NEGATIVE 

AGE 

NUMBER 

Number 

Per  Cent 

Number 

Per  Cent 

Under  6  months. . 

22 

1 

4.54 

21 

95.46 

6  to  12  months.  . 

34 

5 

14.71 

29 

85.29 

39 

13 

33.33 

26 

66.67 

3       ' 

36 

14 

38.89 

22 

61.11 

4       ' 

44 

19 

43.18 

25 

56.82 

5       ' 

51 

24 

47.06 

27 

52.94 

6       ' 

55 

29 

52.73 

26 

47.27 

7       ' 

45 

27 

60.00 

18 

40.00 

8       ' 

45 

28 

62.22 

17 

37.78 

9       ' 

40 

27 

67.50 

13 

32.50 

10       ' 

43 

30 

69.77 

13 

30.23 

11       ' 

35 

22 

62.86 

13 

37.14 

12       * 

44 

29 

65.91 

15 

34.09 

13       ' 

35 

27 

77.14 

8 

22.86 

14       ' 

20 

15 

75.00 

5 

25.00 

Tot 

al 

588 

310 

52.72 

278 

47.28 

actions  is  much  smaller  than  that  of  Hamburger,  shown  in  Table 
V,  a  fact  which  probably  is  due  in  part  to  a  failure  to  repeat  the 
test  or  apply  a  new  test  in  case  of  a  failure  to  react;  but  which 
further  indicates  that  infection  may  not  be  quite  as  general  in 
the  children  of  our  cities  as  it  is  in  Vienna. 

Tables  V  and  VI  from  Hamburger  and  Harbitz  make  an  ex- 


8Untersuchungen  iiber  die  Tuberkulose  im  Kindesalter.  1.  Die  Haufigkeit.  2.  Die 
Formen  der  Tuberkulose.  3.  Angeborene  Tuberkulose  (Vom  pathologische-anatomischen 
Institut  zu   Kristiania)     Norsk   Magazin   for  laegevidenshapen,   No.    1,   p.    1-36,    1913. 

'The  Cutaneous  Tuberculin  Test  in  Children,  Archives  of  Pediatrics,  January,  1915. 


INCIDENCE   OP  INFECTION 


103 


tremely  interesting  comparison,  the   one  showing   clinical,  the 
other  pathological  tuberculosis,  in  European  cities. 


TABLE  VIII. 


Percentage  Giving  Positive  Reactions 


AGE 

CHILDREN    OF 
TUBERCULOUS  PARENTS 

CHILDREN    OF 
NON-TUBERCULOUS  PARENTS 

Number  of  Cases 

Per  Cent 

Number  of  Cases 

Per  Cent 

33 
49 
90 
95 

244 

181 

37 

15.15 
55.10 

68.88 
65.26 
71.31 

74.58 
83.79 

56 

39 

80 

106 

173 

134 

20 

10.07 
33.33 

3  to  4       "      

5  to  6       "      

7  to  10     "     

11  to  14  "     

41.25 
50.00 
64.74 
69.40 
75.00 

Total 

729 

608 

While  these  statistics  show  the  incidence  of  tuberculosis  among 
the  children  of  the  poor  who  visit  the  hospitals  in  crowded  cities 
such  as  Vienna,  Christiana  and  New  York,  they  do  not  tell  us 
the  conditions  in  the  usual  walks  of  life.  I  do  not  know  of 
any  considerable  group  of  children  belonging  to  the  families 
of  the  middle  class  and  the  well-to-do  which  have  been  examined 
carefully  for  tuberculosis.  We  would  not  expect  the  infection, 
however,  to  be  as  general  as  it  is  among  the  poor.  Nevertheless, 
we  are  probably  conservative  in  estimating  that  75  per  cent  of 
all  children  have  an  infection  before  they  reach  the  period  of 
adolescence;  in  fact,  it  seems  almost  a  miracle  that  any  should 
escape.  My  own  experience  would  show  easily  90  per  cent;  but 
the  children  that  I  have  examined  have  been  largely  those  who 
have  associated  with  tuberculosis  in  the  family.  The  most  in- 
teresting and  astounding  statistics  which  have  come  to  my  no- 
tice are  those  of  Jacob,  cited  on  page  79,  showing  the  prev- 
alence of  infection  in  country  districts,  even  where  the  usually 
accepted  dangers  of  infection  do  not  exist. 

Herbert  G-.  Lampson8  made  a  study  of  infection  in  a  num- 
ber of  families  represented  in  both  clinics  and  private  practice, 
which  is  worthy  of  notice.  While  the  inference  that  so  large  a 
percentage  of  infection  has  resulted  from  the  investigated  open 


8A    Study    on    the    Spread    of    Tuberculosis    in    Families. 
University   of  Minnesota,   No.    1,   1913. 


Studies    in    Public    Health, 


104  TUBERCULOSIS  IN   CHILDHOOD 

cases  may  not  be  warranted,  yet  this  careful  study  is  of  great  im- 
portance in  that  it  shows  the  prevalence  of  infection.  I  quote 
the  summary  and  conclusion,  which  is  as  follows: 

"In  thirty-three  families  classed  as  containing  open  cases  of 
pulmonary  tuberculosis,  173  individuals  were  examined.  Of  those 
examined,  124  individuals  showed  evidence  of  tuberculous  in- 
fection, 41  showed  no  evidence  of  tuberculous  infection,  and  8 
individuals  were  doubtful  or  suspicious.  These  suspicious  cases 
were  those  which  showed  more  or  less  signs  of  tuberculous  in- 
fection but  gave  a  negative  von  Pirquet  test;  or  not  showing 
physical  signs,  gave  an  atypical  reaction  to  the  tests  employed. 
All  those  classed  as  infected  with  tuberculosis  gave  a  typical 
reaction  to  the  tuberculin  tests.  Of  the  eight  suspicious  cases, 
one  has  since  been  declared  tuberculous  at  the  University  Dis- 
pensary and  one  has  had  a  pulmonary  hemorrhage;  both  were 
adults  and  neither  is  included  in  the  list  of  tuberculous  infec- 
tions. 

"Among  the  124  showing  evidence  of  tuberculous  infection 
are  the  23  living  center  cases.  Deducting  the  23  center  cases,  we 
have  101  individuals  presumably  infected  from  33  open  center 
cases,  or  3  and  2/33  for  each  case.  Excluding  the  center  cases, 
67  per  cent  of  the  individuals  exposed  showed  evidence  of  in- 
fection with  the  tubercle  bacillus. 

"In  four  families  classed  as  containing  latent  center  cases,  22 
individuals  were  examined.  Of  those  examined  8  showed  evi- 
dence of  tuberculous  infection  and  3  were  suspicious.  Deduct- 
ing the  4  center  cases,  we  have  a  spread  of  infection  in  22  per 
cent  of  individuals  exposed. 

"In  three  families  classed  as  containing  healed  center  cases, 
12  individuals  were  examined.  Of  the  12  examined,  6  showed 
evidence  of  tuberculous  infection.  Deducting  the  three  center 
cases,  we  have  a  spread  of  infection  in  33  per  cent  of  the  in- 
dividuals exposed. 

"In  ten  families  classed  as  containing  non-tuberculous  center 
cases,  56  individuals  were  examined.  Of  the  56  examined,  one 
individual  showed  evidence  of  tuberculous  infection  and  two 
were  suspicious,  an  infection  of  1.7  per  cent  of  all  individuals 
in  the  household. 

"In  five  families  classed  as  controls  and  containing  no  re- 


INCIDENCE   OP  INFECTION  105 

ported  or  suspected  eases  of  tuberculosis,  24  individuals  were 
examined.  Of  those  examined,  one  showed  evidence  of  tuber- 
culous infection,  4.1  per  cent  of  all  individuals  in  the  household. 

"Dividing  all  families  examined  into  two  classes,  tuberculous 
and  non-tuberculous,  there  were  forty  tuberculous  families,  and 
fifteen  non-tuberculous  families.  In  the  forty  tuberculous  fam- 
ilies 207  individuals  were  examined,  of  whom  138  individuals 
showed  evidence  of  tuberculous  infection.  In  the  fifteen  non- 
tuberculous  families  80  individuals  were  examined,  of  whom 
two  showed  evidence  of  tuberculous  infection  and  two  were  sus- 
picious. That  is,  66%  per  cent  of  individuals  examined  in  tuber- 
culous families  showed  evidence  of  tuberculous  infection,  and 
2!/2  per  cent  of  the  individuals  examined  in  non-tuberculous 
families  showed  evidence  of  infection  with  tuberculosis. 

"Among  the  forty  tuberculous  families  there  are  ten  families 
containing  54  individuals,  of  whom  every  member  was  examined, 
and  in  which  every  member  showed  evidence  of  tuberculous  in- 
fection. 

"Three  families  containing  12  members,  of  whom  7  were  ex- 
amined, showed  evidence  of  tuberculous  infection  in  all  those 
examined. 

"In  the  latest  group  there  was  only  one  family  of  seven  indi- 
viduals, of  whom  four  were  examined  in  whom  no  evidence  of 
tuberculous  infection  could  be  found  outside  of  the  center  case. 
An  other  latent  case  in  a  family  of  four  showed  only  one  indi- 
vidual infected,  namely,  the  wife,  and  this  probably  a  coincident 
infection  as  she  had  been  otherwise  exposed.  No  tubercle  bacilli 
have  ever  been  found  in  the  sputum  of  this  center  case.  In  an- 
other latent  case  there  were  five  children  and  the  wife  besides 
the  center  ease,  and  only  one  child  showed  evidence  of  infection. 

"In  another  latent  case  where  both  husband  and  wife  had 
been  reported  open  cases  there  was  but  one  child  out  of  five 
who  showed  evidence  of  infection.  One  of  the  healed  cases 
showed  no  spread  of  infection  in  a  family  of  four.  Another, 
where  the  mother  is  a  healed  case,  shows  two  out  of  four  chil- 
dren with  evidence  of  tuberculous  infection.  In  this  case  the 
history  would  indicate  that  the  lesion  had  healed  before  the 
birth  of  the  two  immune  children.  In  another  case,  where  the 
mother  was  diagnosed  as  an  open  case,  her  health  greatly  im- 


106  TUBERCULOSIS   IN    CHILDHOOD 

proved  before  the  birth,  of  her  second  child,  the  oldest  child 
shows  evidence  of  tuberculous  infection  and  the  two  succeeding 
children  do  not. 

"The  analysis  of  the  non-tuberculous  case  is  simple.  The  one 
case  of  tuberculous  infection  found  in  the  ten  non-tuberculous 
families,  which  had  been  reported  to  the  visiting  nurses  as  tuber- 
culous or  suspected  families,  was  the  wife  of  a  man  who  had 
been  reported  tuberculous,  and  had  been  supervised  for  a  num- 
ber of  years.  He  had  at  one  time  lost  weight  and  at  different 
times  had  hemorrhages,  but  no  record  of  tubercle  bacilli  hav- 
ing been  present  in  his  sputum  could  be  found.  He  showed  no 
signs  of  a  tuberculous  lesion,  and  did  not  react  to  the  tuberculin 
tests.  The  wife  had  not  been  a  suspected  case  and  showed  no 
signs  on  physical  examination,  but  reacted  to  the  tuberculin 
tests.  The  family  of  seven  children,  five  of  them  under  six 
years  of  age,  were  without  any  indication  of  tuberculous  infec- 
tion. One  other  case  with  evidence  of  tuberculous  infection  oc- 
curred in  one  of  my  control  families  where  no  tuberculosis  was 
suspected.  The  woman  who  showed  evidence  of  tuberculous 
infection  gives  a  history  of  having  been  in  delicate  health  for 
two  years  during  childhood.  She  has  five  healthy  non-tuber- 
culous children 

"I  conclude  from  the  above  studies,  first,  that  the  spread  of 
tuberculous  infection  in  families  where  open  cases  of  tuber- 
culosis exist  is  greater  than  it  is  usually  understood  to  be.  Sixty- 
seven  per  cent  of  the  individuals  of  these  families,  excluding  the 
center  cases,  show  evidence  of  tuberculous  infection.  In  no  case 
where  there  has  been  definitely  proven  exposure  of  a  family  to 
an  open  case  of  tuberculosis,  no  matter  what  precautions  have 
been  taken,  have  I  failed  to  find  a  spread  of  infection.  In  at 
least  ten  cases  investigated,  the  infection  has  spread  to  the  limit 
of  available  material.  Every  member  of  these  ten  families 
showed  evidence  of  tuberculous  infection. 

"Second,  that  in  families  where  no  cases  of  tuberculosis  have 
been  found,  no  matter  what  the  home  life  or  living  conditions 
were,  the  number  of  individuals  showing  evidence  of  tubercu- 
lous infection  was  small,  namely,  2^2  per  cent. 

"Third,  that  in  families  where  cases  of  latent  tuberculosis 
exist,  the  spread  of  infection  is  not  as  great  as  in  families  where 


FATE  OF  EAKLY  LESIONS  107 

open  cases  of  tuberculosis  are  found,  22  per  cent  against  67 
per  cent. 

"Fourth,  that  in  families  where  healed  cases  of  tuberculosis 
are  present,  the  spread  of  infection  is  less  than  in  families  where 
open  cases  exist,  33  per  cent  against  67  per  cent. 

"Fifth,  that  in  families  where  no  tuberculosis  is  found,  the 
number  of  individuals  showing  evidences  of  infection  is  very- 
small  (2^/2  per  cent)  in  comparison  with  the  families  in  which 
open,  latent,  or  healed  tuberculosis  exists." 

Fate  of  Early  Lesions. — The  focus  of  disease  which  is  estab- 
lished when  infection  occurs,  the  same  as  all  metastatic  foci 
from  this  original  focus,  may  take  one  of  three  courses :  It  may 
go  on  to  the  rapid  formation  of  active  tuberculosis;  it  may  heal 
at  once,  or  later ;  or  it  may  become  quiescent  for  a  time  to  break 
out  later  in  active  tuberculosis.  As  stated  previously  the  most 
common  course  for  infection  during  the  earliest  years  of  life 
is  to  go  on  to  a  rapidly  fatal  issue,  the  child  yielding  within  two 
or  three  months  to  an  active  tuberculous  process.  In  case  the 
meninges  are  involved,  the  fatal  termination  comes  within  a 
much  shorter  period.  In  cases  which  heal,  a  certain  amount  of 
immunity  is  established  which  protects  the  individual  for  a  longer 
or  shorter  time,  the  length  of  which  probably  varies  greatly 
and  cannot  be  determined  by  any  method  that  we  know.  In 
those  cases  where  the  disease  does  not  go  on  to  a  complete  heal- 
ing but  assumes  a  condition  of  partial  quiescence  and  then  breaks 
down  later  with  renewed  activity,  there  are  factors  both  within 
and  without  the  individual  which  account  for  this  exacerbation. 
On  the  part  of  the  individual  we  assume  that  for  some  reason 
or  other  the  specific  defense  against  the  tubercle  bacillus  is  bro- 
ken down.  We  know  this  occurs  during  the  presence  of  acute 
infectious  diseases,  particularly  measles  and  whooping  cough, 
but  also  during  scarlet  fever  and  diphtheria  and  after  pneumonia. 
In  these  cases,  however,  there  are  probably  other  elements  which 
enter.  I  do  not  doubt  that  the  activity  of  the  glandular  system, 
particularly  that  of  the  bronchial  glands  in  those  diseases  where 
the  pulmonary  tissues  are  involved,  has  considerable  to  do  with 
the  lighting  up  of  tuberculous  foci,  which  may  be  in  the  peri- 
bronchial glands.  The  increased  activity  of  the  glands  during 
these  infections  was  pointed  out  by  Weigart  many  years  ago. 


108  TUBERCULOSIS  IN   CHILDHOOD 

In  our  studies  of  immunity  we  must  not  forget  other  factors 
which,  lower  the  defense  of  the  individual  and  which  are  more 
or  less  beyond  his  control,  particularly  in  the  child,  such  as  the 
surroundings  in  which  the  individual  lives;  the  food  that  he 
eats;  exposure  to  all  kinds  of  unfavorable  conditions,  climatic 
and  other;  various  other  diseases  which  come  and  from  which 
he  recovers  more  or  less  slowly;  also  the  physical  and  mental 
strain  to  which  the  individual  is  subjected.  All  things  else  be- 
ing equal,  the  better  the  condition  which  surrounds  the  indi- 
vidual who  harbors  a  latent  tuberculous  focus,  the  less  the  dan- 
ger of  the  disease  becoming  active.  It  may  be  said  that  this  is 
just  another  way  of  stating  that  every  now  and  then  the  pa- 
tient's specific  immunity  is  probably  broken  down. 

We  cannot  help  believing  that  the  protective  properties  of  the 
tissues  vary  greatly  at  different  times,  under  different  physical 
and  chemical  influences,  and  that  this  is  probably  a  very  impor- 
tant factor  in  the  action  of  the  bacilli  which  may  be  lodged 
within  the  tissues.  We  speak  of  an  increased  virulence  of  bacilli. 
It  is  not  only  possible  but  probable,  that  after  living  in  the  tis- 
sues for  a  long  time,  bacilli  which  have  been  of  low  virulence 
may  change  and  assume  a  virulent  type  the  same  as  virulent 
bacilli  may  become  non-virulent.  Whether  this  is  due  entirely  to 
themselves  or  whether  it  is  due  to  conditions  on  the  part  of  the 
individual  would  be  a  very  interesting  thing  to  know;  but,  at 
the  present  time  we  have  no  clue  by  which  we  may  arrive  at 
this  information. 

The  Effect  of  the  Tuberculous  Infection  Upon  the  Child.— Let 
us  consider  the  effects  of  the  tuberculous  infection  upon  the 
child,  even  in  case  the  lesion  may  not  be  manifest.  We  must  re- 
call that  from  unhealed  lesions  toxins  are  given  off  intermit- 
tently. These  toxins  not  only  affect  the  adjacent  structures  but 
their  influence  may  be  widespread.  They  seem  to  have  a  special 
predilection  for  the  nervous  system,  and  through  it  injure  the 
body  cells.  A  child  who  suffers  from  a  lesion  which  is  subject 
to  frequent  states  of  activity,  nearly  always  suffers  from  gen- 
eral malnutrition,  a  failure  to  grow  and  develop,  and  an  un- 
stable nervous  system. 

Children  suffering  from  these  early  infections  are  not  always 
of  the  so-called  scrofulous  type.     Scrofula  is  a  term  which  has 


EFFECT  OF  INFECTION  UPON  THE  CHILD  109 

been  used  to  describe  an  ill-defined  condition  among  children 
whose  appearance  gives  an  expression  of  lack  of  endurance  and 
who  suffer  from  general  inflammations  of  both  the  skin  and 
mucous  membranes.  This  was  formerly  thought  to  be  a  fore- 
runner of  tuberculosis,  but  its  exact  relationship  to  tuberculosis 
is  not  known.  Some  believed  that  scrofula  is  always  a  result  of 
tuberculous  infection.  Others  believe  that  there  is  a  non-tuber- 
culous scrofula  as  well  as  that  due  to  infection.  Scrofula  is  a 
condition  which  particularly  affects  children  of  the  poor,  so  it 
looks  as  though  it  might  be  a  condition  due  to  either  their  mode 
of  life  or  some  infection  or  toxemia  of  early  years.  Ponfiek9 
and  Schlueter10  in  discussing  this  condition  consider  it  due  to 
anomalies  in  the  structure  of  the  child,  particularly  that  of  the 
lymphatic  system.  They  say  that  the  individual  lymph  ves- 
sels are  narrow,  while  the  lymphatic  spaces  as  a  whole  are  large; 
and  through  the  influence  of  certain  toxins  a  condition  is  brought 
about  where  an  overactivity  of  the  lymphatic  system  is  produced. 
There  is  a  lymph  stasis  and  a  '  swelling  of  the  part  af- 
fected. In  this  condition  the  vessel  walls  are  more  easily  pene- 
trated by  both  toxins  and  bacteria  than  they  are  in  normal  chil- 
dren, consequently  these  children  are  more  prone  to  disturb- 
ances on  the  part  of  the  lymphatic  system  and  are  also  more 
prone  to  general  systemic  disturbances.  Injury  to  the  skin  or 
mucous  membrane  is  followed  by  a  gathering  of  an  extra  num- 
ber of  leucocytes  and  an  unusual  amount  of  pus  formation. 

We  often  find  these  children  stunted  in  growth.  The  infected 
child,  whether  he  belongs  to  the  so-called  scrofulous  class  or  not, 
does  not  develop  properly  if  the  disease  shows  perceptible  ac- 
tivity. He  is  not  able  to  endure.  He  cannot  carry  on  his  school 
work  like  other  children,  neither  can  he  endure  play  as  he  should. 
This  is  often  seen  among  children  of  tuberculous  parents  where 
we  know  opportunity  for  infection  has  occurred;  and,  if  we  wait, 
as  was  so  commonly  the  custom  in  years  gone  by,  the  child  will 
often  go  on  to  a  fatal  tuberculosis.  As  adolescence  is  reached 
these  symptoms  are  more  or  less  exaggerated.  The  young  boy 
or  girl  is  not  able  to  endure  mental  or  physical  strain.  He  may 
be  very  bright  in  his  studies  but  he  falls  back  on  account  of  lack 


9Ober  die  Beziehungen  der  Skrofulose  zur  Tuberkulose,  Verhandlungen  der  Gesellschaft 
fur  Kinderheilkunde,  Aachen   1900,  p.   88. 
10Die  Anlage  zur  Tuberkulose,  Wien,  1905. 


110  TUBERCULOSIS  IN   CHILDHOOD 

of  physical  and  nervous  endurance.  After  this  period  has  been 
reached  the  harm  has  largely  been  done  and  it  is  very  difficult 
to  remedy  it.  A  great  percentage  of  these  children  will  go  on, 
if  left  alone,  and  develop  active  clinical  tuberculosis.  Others 
will  remain  free  from  clinical  tuberculosis  but  be  handicapped 
all  through  life  because  of  the  presence  of  this  infection,  though 
unrecognized.  In  others  the  infection  finally  goes  on  to  active 
clinical  tuberculosis. 

The  Importance  of  Recognizing  Latent  or  Partially  Latent  Le- 
sions in  Early  Life. — Early  lymphatic  tuberculosis  does  not  re- 
ceive the  attention  that  it  should.  Its  recognition  is  in  reality 
the  key  to  the  tuberculous  problem,  so  far  as  both  prevention 
and  cure  are  concerned,  and  therefore  of  prime  importance. 

The  important  studies  of  von  Pirquet,  Hamburger,  Wolf-Eis- 
ner, Gangenhofer  and  others  have  not  only  furnished  clinical  con- 
firmation of  the  pathological  fact  that  nearly  every  man  has  a 
tuberculous  infection  during  life;  but,  having  shown  us  when 
this  infection  occurs,  they  have  shifted  the  scene  of  action  from 
adult  life  to  that  of  childhood.  We  formerly  thought  the  longer 
the  man  lived  the  greater  his  chances  of  becoming  infected,  but 
we  now  know  that  few  that  have  attained  their  fifteenth  year 
have  escaped  infection.  Therefore,  if  we  would  prevent  infec- 
tion or  would  cure  the  infection  when  it  has  taken  place,  we 
should  direct  our  attention  to  childhood. 

This  early  infection  produces  no  symptoms  that  we  have  as 
yet  learned  to  recognize  until  it  takes  upon  itself  a  fair  degree 
of  activity.  It  is  an  infection  of  the  lymphatic  glands,  the  chief 
danger  of  which  lies  in  the  fact  that  it  carries  with  it  the  ever 
present  possibility  of  assuming  a  state  of  activity  and  causing 
destructive  changes  in  the  glands  affected,  and  of  extending  to 
new  tissues.  Even  though  the  glands  themselves  may  not  be  en- 
larged sufficiently  to  be  detected  by  physical  examination  or  the 
x-ray,  they  may  still  be  a  danger  to  the  patient.  This  form  of 
tuberculosis  assumes  its  main  importance  in  childhood.  Its  rec- 
ognition depends  upon  the  tuberculin  test.  In  the  absence  of 
symptoms,  should  a  positive  tuberculin  test  show  in  a  child  in 
whom  careful  examination  reveals  no  lesion  anywhere,  then  we 
are  justified  in  assuming  that  the  infection  is,  as  yet,  probably 
quiescent  and  confined  to  the  lymphatic  glands.     On  the  other 


IMPORTANCE   OP  RECOGNIZING  INFECTION  111 

hand,  should  there  be  symptoms  or  signs  such  as  accompany 
active  tuberculosis,  then  the  condition  should  be  classed  as  ac- 
tive glandular  tuberculosis,  a  condition  which  will  be  described 
later.  The  differentiation  between  these  early  infections  and 
the  next  change  in  the  glands  which  is  marked  by  a  multiplica- 
tion of  bacilli  and  an  increased  activity  in  the  focus  of  infection, 
is  of  utmost  importance  to  the  child  and  its  future  health. 

While  many  of  these  early  lymphatic  infections  do  not  ad- 
vance beyond  this  stage  yet  a  sufficient  number  of  them  progress 
to  justify  careful  consideration.  Postmortems  on  adults  show 
that  there  are  lesions  in  the  apices  of  lungs  in  a  very  large  per 
cent  of  cases.  We  cannot  ignore  the  great  importance  of  the 
fact  that  Hart  shows  64.3  per  cent  in  four  hundred  autopsies 
and  Naegeli  71.43  per  cent  in  his  series.  Most  of  these  are  un- 
suspected during  life;  yet  there  is  no  doubt  that,  did  we  recog- 
nize them  and  ascribe  to  them  their  full  power  for  harm,  we 
would  find  that  in  a  great  many  instances  the  productive  capac- 
ity of  the  individual  had  been  lessened,  even  though  no  mani- 
fest lesions  were  present.  Probably  from  one-third  to  one-half 
of  them  would  at  some  time  show  symptoms  of  clinical  tuber- 
culosis and  probably  not  far  from  one-fifth  of  the  number  would 
die  of  tuberculosis.  Therefore,  the  recognition  of  tuberculosis 
at  any  stage  after  the  bacilli  have  gained  entrance  to  the  or- 
ganism furnishes  information  to  the  attending  physician  which 
is  of  value  to  the  patient. 

Universal  testing  of  children  with  tuberculin  for  the  presence 
of  tuberculous  infection  is  a  measure  which  commends  itself 
strongly.  All  who  react  are  known  to  be  infected.  This  positive 
reaction,  however,  should  not  cause  undue  concern  if  the  child 
remains  healthy ;  but,  should  suspicious  symptoms  arise,  or,  should 
the  child  fail  to  grow  and  develop  properly,  then  further  exam- 
ination should  be  made ;  and,  even  in  the  absence  of  positive  find- 
ings beyond  that  of  a  tuberculin  reaction,  the  child  should  be 
given  the  benefit  of  the  doubt. 

Children  who  are  suffering  from  partially  quiescent  lesions  such 
as  I  have  mentioned  above,  yield  readily  to  proper  care  and  treat- 
ment. They  are  greatly  benefited  by  a  carefully  regulated  life; 
fresh  air,  water,  light  and  sun  baths,  exercise,  and  clothing 
adapted  to  their  needs.    Life  in  the  country  and  in  the  sunlight 


112  TUBERCULOSIS  IN  CHILDHOOD 

is  especially  valuable  for  them.  It  is  also  gratifying  to  see  how 
they  can  be  improved  by  treatment  with  tuberculin.  A  pro- 
longed course  of  tuberculin  given  children  of  this  type  during 
the  age  period  from  five  to  ten  or  twelve  years,  will  often  be  a 
determining  factor  in  their  development.  Even  after  the  lung 
is  involved  they  yield  quite  readily  to  proper  treatment.  The 
child  has  the  advantage  over  the  adult  in  that  it  is  in  the  period 
of  growth  and  development.  This  is  the  period  when  the  body 
cells  should  be  at  their  best  because  they  have  not  yet  been 
injured  by  excesses  of  various  kinds  and  by  various  poisons 
which  have  been  either  taken  into  the  body  or  elaborated  within 
the  body  itself;  consequently,  this  is  a  very  advantageous  time 
for  the  treatment  of  tuberculosis.  If  more  attention  were  given 
the  disease  at  this  time  there  would  be  a  marked  diminution  in 
active  tuberculosis  during  adult  life;  and  probably  no  other 
factor  would  have  a  greater  bearing  upon  the  final  solution  of 
the  tuberculosis  problem. 

Tuberculosis  of  the  Lymphatic  Glands. — The  study  of  tuber- 
culosis of  the  lymphatic  glands  is  of  great  importance  because 
of  its  bearing  upon  the  question  of  early  infection  and  the  grad- 
ual development  of  cellular  immunity.  Glandular  tuberculosis 
is  pre-eminently  an  infection  which  takes  place  prior  to  the  es- 
tablishment of  cellular  immunity.  Non-glandular  infection,  on 
the  other  hand,  is  pre-eminently  an  infection  in  which  the  bacilli 
are  implanted  in  the  tissues  after  a  cellular  defense  has  been 
established,  their  retention  in  the  tissues  depending  upon  the 
reaction  which  occurs  between  the  specifically  sensitized  cells 
and  the  tubercle  bacillus. 

The  behavior  of  the  glands  of  the  mesentery  toward  the  tu- 
bercle bacillus  is  the  same  as  that  of  the  glands  which  drain 
any  other  tissues  which  come  in  intimate  contact  with  the  bacillus, 
such  as  the  cervical,  peribronchial,  and  peritracheal,  as  described 
elsewhere  in  these  pages. 

Tuberculosis  is  primarily  a  lymphatic  disease.  We  mean  by 
this  that  when  tubercle  bacilli  enter  an  organism  which  has  not 
previously  come  in  contact  with  the  same ;  or,  which  has  not  at- 
tained a  high  degree  of  specific  cellular  defense,  the  bacilli  pass 
through  the  mucous  membrane  readily  and,  unless  destroyed 
by  the  lymph  elements,  are  taken  to  the  glands  where  they  form 


TUBERCULOSIS   OF   THE  LYMPHATIC   GLANDS 


113 


a  nidus  and  set  up  foci  of  infection.  It  will  be  noticed  that,  while 
we  do  not  commonly  find  glandular  tuberculosis  in  adults,  yet 
the  preponderance  of  infection  in  childhood  is  glandular  and  the 
greatest  amount  is  found  in  the  first  five  years  of  child  life,  the 
period  in  the  child's  life  before  the  establishment  of  cellular  de- 
fense. This  is  illustrated  by  the  following  table  showing  the 
percentages  of  glandular  tuberculosis  by  age  periods  of  cases 
reported  by  Woodhead  and  Carr: 


165  INSTANCES  OF  TUBERCULOSIS  OF  THE  GLANDS  REPORTED  BY 
WOODHEAD  AND  CARR. 

PERCENTAGE   OF   CHILDREN  SHOWING   TUBERCULOSIS  OF   THE   GLANDS  ACCORDING 
TO  AGE  PERIODS. 


Age 
Period 

Number  of 
Cases 

Percentage  of 
Cases 

Simms  Woodhead — 100  Cases 

1st  year 

1  to  2  34  years 

3  to  5     years 

6  to    7  years 

8  to  10  years 

11  to  15  years 

4 
33 
29 

66 

12 
13 

9 

4 
33 
29 

66 

12 

13 

9 

Carr — 65  Cases. 

1  to  5  years 
Over  5  years 

37 

28 

57 

43 

It  is  extremely  interesting  to  see  that  66  per  cent  of  Wood- 
head's  and  57  per  cent  of  Carr's  cases  of  glandular  tuberculosis 
occurred  before  the  end  of  the  fifth  year.  Carr  also  reports  16 
or  57  per  cent  of  involvement  during  the  first  year  in  another 
series  of  28  cases. 

In  order  to  understand  the  relationship  between  the  instances 
of  tuberculosis  and  these  glandular  infections,  these  statistics 
should  be  compared  with  the  table  taken  from  Hamburger.  It 
will  be  noticed  in  this  table  that  about  50  per  cent  of  children 
are  infected  by  the  time  they  have  reached  the  fifth  year  of  age. 
After  infection  has  occurred,  the  importance  of  glandular  en- 
largement decreases.  From  this  we  can  see  that  tuberculosis  of 
the  glands  gradually  assumes  less  and  less  importance  as  infec- 
tion with  resultant  cellular  defense  becomes  more  general  un- 
til finally,  in  adults,  glandular  tuberculosis  is  comparatively  in- 


114  TUBERCULOSIS   IN    CHILDHOOD 

frequent  and  of  little  concern.  At  this  time  of  life,  in  the  major- 
ity of  individuals,  the  association  with  tubercle  bacilli  has  been 
sufficiently  intimate  to  produce  infection  and  sensitize  the  body 
cells.  When  bacilli,  either  escaping  from  some  focus  already 
present,  into  adjacent  lymph  spaces,  or  passing  through  the  walls 
of  blood  vessels,  or  coming  from  the  outside,  become  implanted 
in  the  tissues,  a  reaction  at  once  takes  place  between  them  and 
the  local  cells  because  of  the  specific  cellular  defense  which  has 
been  developed;  consequently,  the  bacilli  are  held  in  check. 
They  do  not  pass  on  readily  in  the  tissues  nor  are  they  readily 
carried  to  the  regional  glands.  They  remain  in  situ  and  fight 
for  their  existence  at  the  point  of  implantation,  as  shown  in 
Koch's  experiments  on  previously  infected  guinea  pigs,  which 
I  have  so  often  quoted. 

The  Diagnosis  of  Active  Glandular  Tuberculosis. — The  diag- 
nosis of  this  form  of  tuberculosis  is  of  greatest  importance  in 
childhood  and  of  particular  importance  to  those  who  are  treat- 
ing the  children  of  the  poor.  Any  of  the  glands  of  the  body 
may  be  affected,  but  the  cervical  and  bronchial  show  infections 
most  frequently,  the  mesenteric  less  often. 

Tuberculosis  of  the  cervical  glands  may  exist  for  years.  The 
glands  may  be  the  size  of  peas  or  as  large  as  walnuts.  When 
the  process  is  active  they  are  often  swollen  and  painful.  It  is 
sometimes  difficult,  even  impossible,  to  make  a  positive  diagnosis, 
although  painful  swollen  glands  massed  together,  accompanied 
by  symptoms  of  toxemia,  are  exceedingly  suspicious.  If  a  sub- 
cutaneous tuberculin  test  is  given,  evidence  may  be  obtained 
through  a  focal  reaction,  by  an  increase  of  pain  and  swelling, 
but  it  must  not  always  be  expected. 

The  diagnosis  of  active  tuberculosis  of  the  bronchial  glands 
is  not  an  easy  matter.  The  glands  are  deep  seated  and  the  symp- 
toms produced  by  them  are  not  definite.  The  child  may  show 
the  same  signs  as  those  suffering  from  tuberculosis  elsewhere, 
malaise,  lack  of  endurance,  and  failure  to  develop  properly.  He 
is  apt  to  have  some  cough  and  be  especially  prone  to  bronchitis. 
The  temperature  curve  may  show  an  elevation.  In  ease  the 
glands  are  very  large  the  cough  may  assume  a  brassy,  paroxys- 
mal type  and  pressure  symptoms  may  appear.  But  this  is  more 
apt  to  occur  in  adults.     Dullness  may  be  found  over  the  3rd, 


DIAGNOSIS   OF  ACTIVE  GLANDULAR   TUBERCULOSIS  115 

4th  and  5th  dorsal  vertebrae  and  the  x-ray  may  show  shadows. 

An  elevation  of  the  temperature  curve  in  an  underdeveloped 
child,  a  cough,  with  more  or  less  tendency  to  persistent  and  re- 
peated bronchitis,  a  thickening  at  the  hilus,  as  shown  by  the 
x-ray,  and  a  positive  tuberculin  test,  are  strong  evidence  of  an 
active  tuberculous  process  in  the  bronchial  glands.  A  positive 
prompt  reaction  to  tuberculin  is  of  aid  only  in  showing  tuber- 
culosis to  be  present.  It  does  not  indicate  where ;  but,  with  the 
other  conditions  positive,  it  would  point  to  the  bronchial  glands 
as  being  the  probable  seat  of  infection. 

One  of  the  best  clinical  methods  of  determining  tuberculosis 
of  the  bronchial  glands  in  children  is  spinal  auscultation  of  the 
voice,  as  suggested  by  d'Espine.11     This  method  is  as  follows: 

The  patient  is  required  to  pronounce  some  such  numbers  as 
"ninety-nine,"  or  "one,  two,  three,"  as  distinctly  as  possible, 
while  the  examiner  listens  with  the  ear  or  a  stethoscope  with 
small  chest  piece  over  the  cervical  and  upper  dorsal  vertebrae. 
Over  the  cervical  vertebrae  the  voice  is  heard  distinctly  and  has 
clear  tracheal  characteristics.  In  normal  children  this  quality 
of  the  voice  ceases  immediately  at  the  seventh  cervical  vertebra 
where  the  lung  tissue  begins.  When  swelling  of  the  bronchial 
glands  exists,  the  tracheal  character  of  the  tone  persists  below 
this  point  and  may  be  heard  as  low  as  the  fifth  dorsal.  This  is 
the  portion  of  the  chest  occupied  by  the  bronchial  glands  and 
the  bronchial  character  of  the  sound  is  transmitted  by  the  swol- 
len glands  which  surround  the  trachea  and  the  bronchi,  some- 
times filling  the  mediastinal  space  to  the  spinal  column,  produc- 
ing a  good  medium  for  the  transmission  of  the  sound.  Ausculta- 
tion by  the  ear  gives  better  bronchial  sound  than  the  stethoscope, 
but  the  latter  enables  one  to  differentiate  more  accurately,  and 
likewise  causes  an  accentuation  of  the  vocal  fremitus.  When 
auscultation  of  the  spoken  voice  is  uncertain,  it  is  well  to  have 
the  child  whisper  "ninety-nine"  and  listen  carefully  and  sys- 
tematically from  above  downwards  over  the  upper  thoracic 
spines  in  the  same  manner  as  mentioned  above. 

Palpation  should  not  be  omitted  in  the  diagnosis  of  the  media- 
stinal glands.    If  the  examiner,  starting  at  the  first  dorsal  spine 


alEarly    Diagnosis    of    Bronchial    Adenopathy    in    the    Child,    British    Medical    Journal, 
1910,  iii,  p.    1136. 


116  TUBERCULOSIS  IN   CHILDHOOD 

with,  one  finger  on  one  side  of  the  spinous  process,  and  another 
on  the  other,  will  carefully  palpate  the  total  density  under  the 
fingers  he  will  note  in  the  presence  of  enlarged  tracheo-bronchial 
glands  that  there  is  a  distinct  increase  in  resistance  when  that 
portion  of  the  spinal  column  is  palpated  which  is  on  a  level  with 
the  enlarged  glands.  I  find  palpation  even  more  reliable  than 
percussion  in  many  instances  because  it  does  not  cause  confusion 
by  throwing  the  entire  thorax  in  vibration.  Fig.  16  shows  the 
method  of  palpating  for  increased  density  in  the  mediastinum. 
In  examining  for  enlarged  mediastinal  glands  one  must  bear 
in  mind  that  their  position  varies  with  age.  The  bifurcation  of 
the  trachea  is  on  a  level  with  the  third  dorsal  vertebra  or  the 
disc  between  the  third  and  fourth  dorsal  at  birth,  and  gradually 
descends  until  it  reaches  the  seventh  dorsal  in  the  old  man  of 
seventy. 


Fig.  16. — Illustrating  the  method  of  palpating  for  increased  density  in  the  mediastinum. 
Increased  density  is  revealed  to  the  palpating  finger  as  readily  as  it  is  to  the  finger  on 
percussion.     It  shows  as  a  feeling  of  increased  resistance. 


CHAPTEE  V. 

FACTORS  WHICH  PREDISPOSE  TO  TUBERCULOSIS.    WHY 

THE  APEX  IS  INVOLVED.     A  CRITICAL   STUDY  OF 

FREUND'S   THEORY   OF   THE   OSSIFICATION   OF 

THE  FIRST  COSTO-STERNAL  ARTICULATION 

AND  SHORTENING  OF  THE  FIRST  COSTAL 

RING,  AS  PREDISPOSING  FACTORS  IN 

APICAL  TUBERCULOSIS. 

Disposition  and  Predisposition. — No  disease  lias  been  the  sub- 
ject of  more  speculation  and  theorizing  than  tuberculosis.  It 
offers  many  riddles  for  solution  in  every  one  of  its  phases.  The 
relationship  of  human  and  bovine  infection  still  presents  prob- 
lems which  are  not  understood;  the  paths  of  infection;  the  pri- 
mary focus;  the  primary  metastasis  and  methods  of  spreading; 
the  virulence  of  the  process;  the  difference  in  metastases  in  dif- 
ferent tissues;  the  predilection  of  metastatic  tuberculosis  in  the 
adult  for  the  lung  and  the  apex  of  the  lung ;  the  question  of  im- 
munity; natural  and  specific  resistance;  are  only  a  few  of  the 
anatomic-pathologic  riddles,  the  solution  of  which  will  aid  great- 
ly our  understanding  of  this  many  sided  disease. 

Speculation  as  to  the  specific  cause  of  tuberculosis  was  set  at 
rest  for  all  time  by  the  work  of  Koch  showing  that  it  is  due  to 
a  micro-organism.  However,  this  has  not  settled  the  question 
in  the  minds  of  all  as  to  whether  the  tubercle  bacillus  is  the  only 
cause;  or  whether  there  are  other  special  predisposing  factors 
on  the  part  of  the  individual,  which  are  partly  responsible  for 
the  development  of  the  disease.  In  order  to  determine  any  spe- 
cific factor  which  predisposes  to  infection  we  must  search  for 
something  which  is  common  to  nearly  every  member  of  the  race 
because  infection  occurs  in  nearly  all  human  beings  sometime 
during  their  lives ;  but  this  is  not  the  principal  question  that  we 
are  endeavoring  to  solve  in  our  search  for  factors  predisposing 
to  this  disease.  We  are  trying  to  determine  whether  or  not 
there  is  any  special  condition,  whether  it  be  in  the  physical  or 


118  FACTORS   WHICH  PREDISPOSE   TO  TUBERCULOSIS 

chemical  constitution  or  the  reactivity  of  the  cell;  or  whether 
it  be  in  some  special  predisposition  of  certain  organs;  and 
whether  this  is  anatomical  or  whether  it  is  pathological.  These 
problems,  it  must  be  understood,  from  the  very  nature  of  the 
case,  are  extremely  difficult  to  solve. 

One  thing  is  patent  to  all  who  are  studying  this  question: 
that  is  the  fact  that  the  subject  of  the  predisposition  of  certain 
individuals  and  of  certain  organs  to  infection  seems  to  receive 
nearly  as  much  attention  today  as  it  did  prior  to  the  tubercle 
bacillus  era.  Whether  this  is  simply  due  to  the  firm  impression 
of  old  ideas,  the  impossibility  of  getting  away  from  tradition; 
or,  whether  it  is  a  real  problem  begging  for  solution,  cannot  be 
definitely  settled;  but,  until  settled,  it  rightfully  demands  its 
share  of  discussion. 

Phthisical  habitus  is  practically  as  old  as  medicine.  Scrofula 
is  almost  of  equal  age.  The  small  heart  and  narrowing  of  the  ar- 
teries has  been  under  discussion  for  three-quarters  of  a  century. 
The  interest  in  mechanical  predisposition  as  suggested  by  Freund 
in  1858  and  1859,  and  emphasized  later  by  Hart,  and  as  sug- 
gested by  Schmorl,  Birch-Hirschfeld,  and  Eothschild  is  of  much 
later  date ;  while  the  ideas  which  particularly  have  to  do  with 
the  bio-chemical  side  of  the  question  are  of  comparatively  recent 
date. 

While  the  study  of  disposition  and  predisposition  is  extremely 
interesting  and  is  not  without  value,  yet  we  must  not  lose  sight 
of  the  fact  that  the  mass  and  virulence  of  the  tubercle  bacilli 
in  the  inoculation,  are  factors  of  tremendous  importance  in  de- 
termining not  only  infection  but  the  course  of  the  disease  there- 
after.    This  I  have  discussed  in  Chapter  III. 

Pulmonary  Focus. — Metastatic  Tuberculosis. — The  tubercle  ba- 
cillus has  a  tendency,  when  first  taken  into  the  body,  to  settle 
in  the  lymph  glands.  If  it  enters  through  the  tonsil  or  mucous 
membranes  of  the  mouth  it  passes  at  once  to  the  lymph  glands 
that  drain  these  regions.  If  it  passes  directly  into  the  lung, 
along  with  the  inspired  air  or  indirectly  through  the  intestines 
and  thoracic  duet,  it  may  form  a  primary  nidus  in  the  lung,  but 
the  preponderance  of  the  infection  takes  place  in  the  peribron- 
chial lymph  glands  which  drain  the  particular  area  of  lung  tis- 
sue involved.      If  it  passes  through  the  intestinal  wall  without 


METASTATIC    PULMONARY   FOCI  119 

producing  a  distinct  local  disturbance,  it  may  pass  on  into  and 
produce  infection  of  the  corresponding  lymph  glands  or  be  taken 
up  by  the  lacteals,  carried  through  the  thoracic  duct  and  poured 
into  the  circulating  blood  to  be  strained  out  in  the  lung  or  in  some 
other  portion  of  the  body,  there  to  produce  a  local  lesion.  The 
character  of  this  local  lesion  will  depend  on  whether  or  not  the 
individual  has  been  previously  infected.  If  a  primary  inocula- 
tion, the  infection  will  have  a  tendency  to  escape  the  focus  and 
go  on  to  the  neighboring  lymph  glands ;  but,  if  it  is  a  reinocula- 
tion,  the  sensitized  cells  will  attempt  to  localize  the  infection  in 
the  tissues  where  first  implanted. 

Chronic  tuberculosis,  particularly  tuberculosis  of  adult  life, 
is  probably,  in  the  great  majority  of  instances,  due  to  metastases 
from  some  previous  focus.  These  metastases  occur  because,  for 
some  reason,  tubercle  bacilli  which  are  shut  up  in  the  glands  of 
the  body,  become  active,  multiply,  break  through  the  tissues 
which  surround  them,  gain  access  to  -the  lymph  or  blood  stream, 
usually  the  latter,  and  find  their  way  to  other  parts  to  be  strained 
out  wherever  the  capillaries  are  sufficiently  small  to  detain  them, 
or  wherever  the  blood  and  lymph  flow  is  sufficiently  retarded  to 
permit  them  to  remain  in  situ  long  enough  to  produce  infection. 

I  have  little  doubt  that  the  greatest  factor  in  the  prevention 
of  this  secondary  spread  from  the  primary  lymphatic  focus  is 
the  patient's  immunity,  the  sensitization  of  the  cells, — the  spe- 
cific cellular  defense  which  has  been  built  up  by  the  presence 
of  the  tuberculous  focus  in  these  glands.  In  consequence  of 
this,  when  bacilli  gain  entrance  to  the  blood  or  lymph  stream 
and  are  carried  to  new  tissues ;  or,  it  may  be,  to  distant  organs, 
they  meet  cells  which  are  sensitized  toward  them,  which  have 
developed  specific  defensive  powers,  and  stimulate  these  cells  so 
that  they  prevent  a  new  infection  from  occurring.  This  is  prob- 
ably an  important  factor  in  making  late  childhood  compara- 
tively free  from  metastatic  infection  in  any  part  of  the  body  and 
the  greatest  factor  in  making  metastatic  tuberculosis  in  the  adult 
a  chronic  disease. 

The  reason  tuberculosis  in  infants  is  more  often  fatal  than  In 
adults,  and  tuberculosis  in  sucklings  more  fatal  than  in  older 
children  (as  shown  by  Tables  I  and  II,  Chapter  IV)  is  because 
the  child  has  not  had  time  to  successfully  fight  inoculations  of 


120  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

tubercle  bacilli  and  develop  a  high  degree  of  specific  immunity 
thereby.  Specific  cell  sensitization,  the  specific  body  resistance, 
has  not  yet  been  built  up,  consequently  the  young  child  is  un- 
able to  withstand  doses  of  tubercle  bacilli  of  any  great  size. 
Doses  of  tubercle  bacilli  which  produce  rapidly  progressive 
tuberculosis  in  the  infant  might  gain  entrance  to  the  blood  or 
lymph  channels  of  older  children  or  adults  and  produce  no  symp- 
toms whatever.  So,  we  might  reason,  that  inasmuch  as  the  spe- 
cific defense  against  tuberculosis  is  a  matter  of  cellular  activity, 
some  change  in  the  chemical  reactivity  of  the  cell  which  might 
be  present  at  times  and  interfere  with  cellular  activity  might 
prove  to  be  a  predisposing  factor.  But  of  its  existence  we  are 
not  sure. 

We  recognize  the  fact  that  tubercle  bacilli  often  escape  from 
glandular  foci  and  produce  metastases.  The  figures  of  Hart  and 
Naegeli  show  that  63.4  and  71.3  per  cent  respectively,  of  adult 
bodies  examined,  harbor  infections  which  have  been  carried  to 
the  lungs,  usually  the  apex ;  but  it  is  a  much  smaller  percentage 
of  these,  only  about  one-half,  that  show  a  progressive  tuber- 
culosis. It  is  possible  that  the  progressive  cases  are  due  to  some 
lack  of  cell  resistance  or  some  special  predisposing  mechanical 
factors;  but  we  cannot  get  wholly  away  from  the  fact  that  the 
mass  of  infection  and  the  virulence  of  the  bacilli  are  important 
determining  factors  in  the  future  progress  of  the  metastatic 
focus.  In  our  future  study  of  the  chemistry  of  the  blood  and 
lymph  and  the  chemistry  of  the  cells  of  the  body  and  the  various 
problems  of  cellular  reactivity,  we  will  in  all  probabilities  obtain 
something  of  value  in  the  solution  of  these  problems. 

Commonly  Recognized  Factors  Predisposing  to  the  Formation 
of  Pulmonary  Metastases. — The  more  we  study  tuberculosis  the 
more  we  are  led  to  believe  that  whether  any  special  predisposi- 
tion towards  the  disease  exists  in  certain  individuals  or  not, 
nevertheless  any  individual  may  become  infected  and  develop 
clinical  tuberculosis,  providing  he  receives  an  inoculation  of  a 
sufficiently  large  number  of  tubercle  bacilli. 

There  are  probably  many  factors  which  might  lower  an  indi- 
vidual's resisting  power  and  predispose  for  a  time,  not  only  to 
tuberculosis,  but  to  any  other  disease.  Living  in  bad  surround- 
ings, improper  nourishment,  overwork  and  excesses  at  one  time 


FACTORS  FAVORING  PULMONARY   METASTASES  121 

might  prove  to  be  the  determining  factors  in  an  active  clinical 
tuberculosis;  when,  in  other  instances,  conditions  being  differ- 
ent, the  relationship  of  the  tubercle  bacillus  to  the  individual 
not  being  the  same,  they  would  fail  to  precipitate  the  disease. 
Chronic  illness,  particularly  one  which  has  reduced  the  patient's 
strength,  might  be  a  predisposing  factor  not  only  for  infection 
but  for  a  metastasis  to  occur  and  for  clinical  tuberculosis  to 
show  itself.  As  a  rule,  however,  these  predisposing  factors  must 
not  be  looked  upon,  as  far  as  we  know,  as  being  specific.  They 
are  only  a  part  of  the  great  number  of  factors  which  might  ap- 
pear to  favor  the  development  of  the  disease.  Several  of  them 
may  appear  in  the  same  individual  at  the  same  time. 

The  question  of  racial  predisposition  to  tuberculosis  is  some- 
times mentioned,  but  there  are  so  many  factors  which  enter  into 
the  discussion  of  this  question  that  it  is  not  fair  to  say  that  be- 
cause a  large  percentage  of  a  certain  race  has  tuberculosis  that 
it  is  especially  predisposed.  It  is  necessary  to  look  into  the 
life  habits  of  that  race,  to  see  how  its  members  live,  to  see  what 
factors  there  are  which  have  a  tendency  to  lower  their  vitality 
and  make  them  prone  to  tuberculosis,  before  such  a  broad  state- 
ment can  be  made.  This  is  true  of  the  negro  in  America.  The 
conditions  under  which  he  works  and  lives  have  a  tendency  to 
make  him  more  prone  to  infection.  On  the  other  hand  we  must 
not  forget  that  in  his  case  there  is  lacking  that  strong  racial  im- 
munity which  we  find  in  other  peoples  whose  ancestors  have 
had  tuberculosis  for  centuries.  He  is  one  who  has  more  re- 
cently come  from  primitive  conditions  where  tuberculosis  did 
not  exist. 

The  fact  that  tuberculosis  is  not  common  among  the  members 
of  the  Jewish  race,  excepting  among  the  poorer  element  is  most 
likely,  in  part,  a  racial  immunity ;  but,  also  in  part,  due  to  their 
habits  of  life. 

If  some  valid  reason  can  be  given  why,  in  adults,  the  lungs, 
and  particularly  the  apices  of  the  lungs  are  nearly  always  the 
seat  of  the  infection  by  the  tubercle  bacillus,  it  will  help  in  solv- 
ing many  of  the  other  problems  of  infection.  No  matter  how 
the  tubercle  bacillus  gains  access  to  the  body,  whether  through 
the  upper  or  lower  air  passages,  or  through  the  tonsils  or  mu- 
cous membranes  of  the  mouth,  or  through  the  lower  intestinal 


122  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

tract,  when  the  time  comes  for  clinical  tuberculosis  to  manifest 
itself  the  infection  is  nearly  always  in  the  lung,  and  not  only 
in  the  lung  but  in  the  apex  of  the  lung;  while  nearly  all  extra- 
pulmonary lesions  in  the  adult  are  metastatic  complications  from 
a  pulmonary  focus. 

It  is  generally  assumed  that  the  pulmonary  tissue  is  particu- 
larly adapted  to  the  implantation  and  growth  of  the  tubercle 
bacillus,  the  same  as  the  tonsil  is  adapted  to  diphtheria,  Pyre's 
patches  to  the  typhoid  bacillus,  and  the  skin  to  the  infectious 
agent  of  smallpox.  "Whether  this  assumption  "will  hold  or  not 
will  have  to  be  determined.  Already  a  very  important  fact 
shakes  one's  faith  in  the  assumption, — the  fact  that  the  primary 
infection  in  childhood,  if  we  accept  the  general  belief  of  pathol- 
ogists; or,  the  primary  metastasis,  if  we  accept  the  views  of 
Ghon,  is  found  in  the  lymphatic  glands  and  not  in  the  lungs. 
If  we  believe  with  Ghon  that  the  primary  focus  is  in  the  lung 
and  that  the  peribronchial  glands  are  secondarily  involved,  we 
are  still  forced  to  recognize  the  fact  that  the  lymphatic  glands 
seem  to  be  especially  prone  to  infection  with  bacilli ;  for  the  pri- 
mary pulmonary  focus,  as  a  rule,  is  small,  with  little  tendency 
to  infect  adjacent  structures,  while  the  infection  after  reaching 
the  glands  finds  soil  suitable  for  multiplication  and  growth  suffi- 
cient to  cause  a  considerable  inflammation  and  enlargement  of 
the  structures.  The  parallel  between  this  and  the  inoculation 
experiments  in  healthy  animals  as  first  reported  by  Koch  is  evi- 
dent. It  might  also  be  suggested  that,  owing  to  the  relatively 
large  lymph  spaces  of  the  child1  bacilli  pass  out  of  the  primary 
focus  with  such  dispatch  that  they  are  not  given  time  to  become 
implanted,  but  are  carried  to  and  find  lodgment  in  the  glands. 
That  this  may  be  another  reason  why  the  glands  are  so  promi- 
nent in  infection  in  early  life,  is  further  suggested  by  the  fact 
that  the  inhalation  of  dust  in  childhood  shows  marked  deposits 
in  the  subpleural  lymph  spaces  and  bronchial  glands,  but  little 
or  none  in  the  lungs,  as  shown  by  Shingu2  while  the  same 
experiment  in  adults  shows  the  lung  tissue,  particularly  the 
apical  tissue,  filled  with  pigment.  It  would  seem  that  primarily 
in  the  child  there  is  a  possibility  that  the  lymphatic  structures 


iCornet:     Die  Tuberkulose,   1st  ed.,   Alfred  Holden,   Wien,   1899,  p.   288. 
2Staubinhalation   bei   Kindern,    Virchow's   Archives,   Bd.    200. 


FACTORS   FAVORING  IMPLANTATION  123 

are  better  adapted  to  the  bacillus  than  the  pulmonary  tissue.  If 
this  is  a  fact  we  must  then  look  for  causes  other  than  selection 
because  of  suitability  of  tissue,  to  explain  why  pulmonary  tuber- 
culosis so  greatly  predominates  over  all  other  forms  of  disease 
in  the  adult. 

Let  us  conceive  of  tuberculosis  as  a  disease  with  a  primary 
focus  in  the  lymphatic  glands  usually  in  the  peribronchial  glands, 
from  which  metastases  are  now  and  then  taking  place.  This  con- 
ception is  the  same  as  that  of  streptococcus  infection  of  the  ton- 
sil or  gums  causing  metastases  in  the  various  organs,  as  described 
by  Rosenow,  or  the  metastases  in  cancer.  From  the  primary 
focus,  bacilli  gain  access  to  the  blood  stream,  or  at  times  to  the 
lymphatics  and  are  carried  to  other  parts  of  the  body  to  points 
where  metastatic  foci  appear.  This  may  be  in  the  lung,  meninges, 
kidney,  liver,  bones,  joints,  in  fact,  any  part  or  organ  of  the 
body. 

That  the  blood  and  not  the  air  passages  is  the  chief  factor  in 
carrying  tubercle  bacilli  to  the  apex  of  the  lung  is  evident  from 
the  comparison  with  air-borne  diseases  as  discussed  on  page  67. 
Air-borne  diseases  affect  the  base  and  central  portion  of  the 
lung,  that  portion  which  receives  the  inspired  air  most  directly 
and  in  which  the  movement  of  the  air  is  greatest,  while  the  blood- 
borne  diseases  affect  that  portion  where  the  movement  is  least, 
giving  opportunity  for  implantation  to  occur. 

Whether  tubercle  bacilli  undergo  transmutation  while  in  the 
body,  and  this  makes  those  of  certain  characteristics  or  certain 
degrees  of  virulence,  attack  one  tissue,  and  others  attack  an- 
other, as  is  true  of  the  streptococcus  (Rosenow),  must  be  left 
for  future  study ;  so  must  the  question  of  whether  or  not  bacilli 
of  the  bovine  type  are  prone  to  infect  certain  structures  and 
those  of  the  human  type  others;  and,  whether  or  not,  bovine 
bacilli,  by  long  residence  in  the  human  body,  change  into  the 
human  type.  There  are  certain  anatomical  changes,  however, 
which  deserve  attention  for  their  influence  on  the  localization  of 
tuberculous  infection,  even  though  the  different  tissues  offer 
varying  degrees  of  susceptibility  to  infection,  and  even  if  it 
should  be  found  that  bacilli  undergo  transmutation. 

Bacilli  are  capable  of  penetrating  the  walls  of  the  blood  ves- 
sels.   The  finding  of  bacilli  in  the  blood  of  tuberculous  patients 


124  FACTORS   WHICH  PREDISPOSE   TO  TUBERCULOSIS 

offers  proof  of  this.  No  matter  whether  this  takes  place  through 
normal  vessel  walls  or  only  through  those  which  are  involved 
in  the  inflammation  of  the  tubercle,  foci  in  which  bacilli  are 
multiplying  are  sources  of  dissemination  and  danger  to  the  or- 
ganism. Old  foci  are  now  believed  to  be  the  most  frequent 
sources  of  adult  tuberculosis  (Homer).  An  old  focus  in  a  lymph 
gland  or  other  tissue  may  at  any  time  take  upon  itself  a  state  of 
active  necrosis  and  set  up  irritation  in  the  walls  of  adjoining 
vessels,  permitting  bacilli  to  pass  through  into  the  lumen  and  be 
carried  on  with  the  blood  stream  until  destroyed  or  implanted 
in  some  other  portion  of  the  body.  Aufrecht  has  described  this 
as  taking  place  and  studied  sections  showing  the  bacilli  passing 
through  the  vessel  wall. 

Once  in  the  vessel,  bacilli  follow  the  course  of  the  blood 
through  the  heart,  lungs  and  systemic  vessels.  They  may  find 
lodgment  in  any  part  of  the  body;  but  in  fact,  in  adults  rarely 
find  lodgment  anywhere  except  in  the  lungs  until  after  the  lungs 
are  once  infected.  To  account  for  implantation  occurring  in 
other  tissue  I  consider  the  capillaries  of  the  body,  both  those  of 
the  pulmonary  and  systemic  circulation,  as  a  system  of  fine 
screens.  In  some  places  injuries  occur  to  these  screens,  the  mesh 
becoming  smaller;  in  other  places  it  is  not  improbable  that  the 
mesh  may  be  made  smaller  by  pressure.  If  smaller,  for  any 
cause,  the  mesh  offers  a  barrier  to  the  passage  of  material  of 
whatever  kind  that  attempt  to  pass  through.  The  rapidity  of 
the  circulation  is  another  factor  in  passing  the  screen,  the  slower 
the  circulation  the  greater  the  danger  of  particles  becoming 
entangled  in  the  mesh. 

Localization  in  the  Child  and  the  Adult  Differs. — Two  patent 
facts  stand  out  as  regards  pulmonary  tuberculosis  in  childhood 
as  compared  with  pulmonary  tuberculosis  of  adult  life;  first,  it 
is  relatively  infrequent,  and,  second,  the  localization  does  not 
show  a  selective  preference  for  the  apex  of  the  lung.  In  other 
words,  the  bacilli  are  nearly  as  apt  during  childhood  to  be 
screened  out  in  one  portion  of  the  body,  with  certain  limitations 
of  tissues  and  organs,  as  in  another;  and  in  the  lower  lobes  of 
the  lung  as  in  the  upper;  as  will  be  seen  by  the  following  table 
from  Ghon,  showing  the  localization  of  primary  pulmonary  foci. 


LOCALIZATION   OF  PULMONARY   LESION 


125 


Ghon's  Anatlsis  of  170  Cases  of  Primary  Tuberculous  Foci  of  the 
Lung  Shows  the  Following  Distribution: 


No. 

Number  of  cases 
according  to 
number  of 

pulmonary  foci 

DISTRIBUTION  of  pulmonary  foci 

Percentage 
relationship 

of 
Cases 

Right 
upper 
lobe 

Right 

middle 

lobe 

Right 
lower 
lobe 

Left 
upper 
lobe 

Left 
lower 
lobe 

No. 

of 

foci 

to  entire 

number  of 

foci 

170 

142  cases  with 

1  focus 

15  cases  with 

2  foci 

5  cases  with 

3  foci 

2  cases  with 

4  foci 

44 

10 

3 

11 

3 

32 
2 
1 
4 

33 

12 

5 

22 
3 
6 
4 
5 

? 

142 

30 

15 

8 

5 

? 

71.00% 

15.00% 

7.50% 

4.00% 

2.50% 

1  case  with 
5  foci 

5  cases  inwhich 
foci  cannot  be 
determined  . . 

? 

? 

? 

? 

? 

Number  of  pulmonary 
foci  divided  accord- 

57 

14 

39 

50 

40 

200 

Percentage  relationship 
to  entire  number  of 
foci 

28.50 
/o 

7.00 

% 

19.50 

% 

25.00 

% 

20.00 

% 

The  study  of  this  question  leads  us  into  the  realms  of  both 
speculation  and  anatomical  facts.  After  infection  has  once  oc- 
curred the  child  seems  to  be  relatively  resistant  to  the  disease, 
as  suggested  by  the  fact  that  the  disease  does  not  regularly  spread 
and  form  new  metastases  during  this  age  period.  While  it  is 
difficult  to  offer  a  satisfactory  explanation  for  this,  I  would  sug- 
gest that  the  following  are  factors.  It  is  probably  partly  be- 
cause of  the  specific  immunity  which  the  child  has  but  recently 
developed;  partly  because  of  certain  biochemical  properties  on 
the  part  of  the  tissues  of  the  child  which  make  it  more  re- 
sistant; and  partly  because  the  bacilli  are  not  screened  out  of 
the  blood  stream  when  they  gain  access  to  it,  but  are  kept  in 
the  circulating  fluid  until  they  are  destroyed.  At  any  rate, 
some  factors  are  operating  in  childhood  which  do  not  seem  to 
operate  so  successfully  in  later  life,  which  have  a  tendency  to 
prevent  the  disease  from  spreading  to  any  portion  of  the  body, 


126 


FACTORS   WHICH  PREDISPOSE   TO   TUBERCULOSIS 


particularly  the  lungs,  even  although  the  infective  bacilli  are 
present. 

At  least  a  partial  answer  to  the  queries  why  portions  of  the 
body  other  than  the  lung,  in  children,  are  as  apt  to  be  involved 
as  the  lungs  themselves,  and  why  one  portion  of  the  lung  seems 
as  prone  to  involvement  as  another,  while  the  apex  of  the  lung 
seems  especially  predisposed  in  the  adult,  is  suggested  by  the  fol- 
lowing anatomical  considerations. 


Fig.  17. — Illustrating  schematically  the  difference  in  the  elevation  of  the  anterior  portion 
of  the  ribs  of  children  and  adults.  A,  at  birth,  first  rib  on  level  with  first  dorsal  vertebra; 
B,  in  adult,  first  rib  on  level  with  third  dorsal  vertebra. 

At  birth  the  anteroposterior  diameter  of  the  upper  portion  of 
the  chest  is  relatively  great,  the  chest  is  rotund.  The  top  of  the 
sternum  is  on  a  level  with  the  first  dorsal  (or  even  the  seventh 
cervical)  vertebra.  Under  natural  conditions,  the  anterior  por- 
tion of  the  chest  begins  to  sink  during  the  first  year  of  life,  and, 
by  the  fifth  or  sixth  year,  the  top  of  the  sternum  is  on  a  level  with 
the  disc  between  the  second  and  third  thoracic  vertebras  (Piersol) 


CHANGES  IN   CONTOUR   OF   CHEST   OF   CHILD 


127 


as  shown  in  Fig.  17.  Coincident  with  this  descent  of  the  an- 
terior end  of  the  ribs  and  sternum,  the  upper  portion  of  the 
chest  flattens.  Under  pathological  conditions  this  may  occur 
earlier.  I  have  seen  a  marked  pathological  flattening  of  the  up- 
per part  of  the  chest,  usually  unilateral,  in  children  from  two 
to  six  or  eight  years  of  age,  where  tuberculous  infection  of  the 
apex  existed.  This  natural  flattening  which  takes  place  as  the 
child  grows  older  results  from  the  dropping  of  the  anterior  por- 
tion of  the  chest  wall,  as  a  result  of  assuming  the  erect  position. 
Coincident  with  the  descent  of  the  anterior  portion  of  the  ribs 
and  sternum,  a  marked  change  in  the  shape  of  the  chest  occurs 
and  a  change  in  the  respiratory  motion  of  the  various  portions 
of  the  lungs  takes  place.  The  round  chest  of  the  infant  gradu- 
ally gives  way  to  the  wide  chest  of  the  adult  and  the  superior 
portion  of  the  chest  becomes  relatively  flatter  than  the  lower 
portion.  In  the  child  the  anteroposterior  diameter  of  the  chest 
below  the  second  costal  cartilage  is-  to  the  transverse  diameter  as 
2  is  to  3  at  birth,  and  as  1  is  to  2  at  three  years  of  age,  while  it 
is  as  1  to  21/2  or  1  to  3  in  adult  life  (Piersol).  These  relationships 
at  the  second  costal  cartilage,  as  mentioned  by  Piersol,  may  be 
shown  in  a  way  to  be  appreciated  by  the  following  quadrangles 
(Fig.  18,  A,  B  and  C). 


■I  nse 


Fig.  18. — Illustrating  the  relationship  between  the  anteroposterior  and  transverse  diam- 
eters of  the  chest  below  the  second  costal  cartilage.  A,  at  birth;  B,  at  three  years  of 
age;   C,  during  adult  life. 


The  change  in  the  growth  of  the  lung  in  the  adult  as  com- 
pared with  the  infant  is  also  important.  According  to  Aeby,3 
there  are  two  periods  during  which  very  rapid  growth  of  the 
lung  occurs, — the  latter  half  of  the  first  year  and  the  period  of 
puberty.  At  the  end  of  the  first  year  the  lung  is  four  times  as 
large  as  it  is  at  birth;  at  eight  years,  eight  times  as  large;  at 


3Der  Bronchialbaum  der   Saugetiere  und   des   Menschen,   Leipzig,   Wilhelm   Fnglemann, 
1880. 


128  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

puberty  ten  times  as  large  and  immediately  following  puberty, 
twenty  times  as  large.  As  the  lung  increases  in  size  the  bony 
framework  above  expands  the  least  of  any  part  of  the  thorax 
and  this  emphasizes  the  compression  of  the  pulmonary  par- 
enchyma at  the  apex,  and  this,  in  turn,  favors  infection  at  this 
period  of  life. 

The  breathing  of  the  new-born  child  is  of  necessity  abdominal. 
Thoracic  breathing  is  impossible  because  of  the  already  high 
position  of  the  sternum  and  ribs.  Inspiratory  effort  cannot 
raise  them  higher.  Bartenstein  and  Tada4  say  that  thoracic 
breathing  is  dependent  upon  and  due  to  the  child's  assuming 
the  upright  position,  standing  and  walking  bringing  it  about. 

Gregor,  quoted  by  Bartenstein  and  Tada,  calls  attention  to 
the  difference  in  the  respiratory  compensation  in  the  new-born 
and  the  adult.  The  former  can  easily  double  the  frequency  of 
respiration  as  demanded,  but  cannot  increase  the  depth  to  any 
extent,  while  the  adult  increases  slightly  in  frequency  but  more 
in  depth.  This  is  significant  in  its  effect  on  the  mechanics  of 
the  thoracic  cage.  In  the  former,  the  movement  is  great,  af- 
fecting the  entire  lung ;  in  the  latter  the  deeper  inspiration  affects 
the  base  and  lower  portions  of  the  lung  to  a  much  greater  ex- 
tent than  the  upper  portion;  because  at  the  base  the  full  effect 
of  the  contraction  of  the  diaphragm  is  exerted,  as  well  as  that  of 
elevating  the  larger  and  more  movable  ribs. 

Mehnert5  also  contributed  an  important  study  to  this  question 
of  developmental  and  acquired  change  in  the  thorax.    He  says: 

"In  the  primitive  bony  thorax  of  the  17  mm.  embryo  (Fig. 
19 A)  the  sixth  rib  lies  almost  straight  and  forms  an  angle  of 
about  90  degrees  with  the  long  axis  of  the  body. 

"In  the  child  of  4  years  (Fig.  195)  the  inclination  of  the  axis 
of  the  same  rib  has  already  reached  8°.  Inasmuch  as  this  change 
takes  place  about  equally  from  year  to  year  during  this  period,  it 
shows  an  average  change  of  2°  a  year. 

"The  sixth  rib  of  the  36  year  old  man  (Fig.  190)  has  already 
reached  an  inclination  of  26°  or  an  increase  of  18°  over  the  4 


4Beitrage  zur  Lungenpathologie  der  Saiilinge,  Franz  Deuticke,  Wien  and  Leipzig,  1907. 

BEJ.  Mehnert:  Uber  topographische  Altersveranderungen  des  Atmungsapparates  und 
ihre  mechanischen  Verkniipfungen  an  der  Leiche  und  am  Lebenden,  Gustav  Fischer, 
Jena,  1901. 


DIFFERENCE   IN   INCLINATION    OF   RIBS 


129 


130  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

year  old  child,  which  has  taken  place  during  a  period  of  32 
years.  The  yearly  increase  in  inclination  during  this  period  is 
about  y2°. 

"The  difference  in  the  angle  of  inclination  of  the  36  year  old 
man  and  the  72  year  old  man  (Fig.  19D)  is  9°  which  takes 
place  during  36  years,  giving  a  change  of  %°  per  year. 

"These  individuals  belonging  to  four  arbitrarily  chosen  age 
periods  show  that  the  inclination  of  the  rib  continues  during 
the  entire  period  of  life,  but  that  it  does  not  make  the  same 
progress  at  all  periods,  but  decreases  with  years.  In  the  first 
years  of  postfetal  life  the  inclination  increases  2°  yearly.  In 
the  next  thirty  years  the  progress  of  this  inclination  is  four 
times  less.    Still  less  is  the  progress  of  the  rib  inclination  in  ad- 


A 

Fig.  20. — Illustrating  the  relative  increased  anteroposterior  compression  of  the  apex 
which  takes  place  in  man  as  the  result  of  assuming  the  erect  position,  as  compared  with 
the  four-legged  mammals.     A,  four-legged  mammal;  B,  man.      (Keith.) 

vanced  years.  It  is  less  than  half  as  great  as  it  is  in  the  pre- 
vious period  and  only  one-eighth  as  great  as  in  the  first  years 
of  life.  There  can  be  no  doubt  that  the  inclination  of  the  ribs 
is  the  direct  result  of  the  pulling  which  the  weight  of  the 
thoracic  organs,  the  liver,  and  the  filled  stomach  exert  upon 
the  diaphragm  and  bony  thorax." 

It  is  significant  that  with  the  changes  in  the  bony  thorax 
which  comes  on  in  man  with  increasing  years,  and  which  results 
from  his  assuming  the  erect  posture,  comes  a  change  in  the 
localization  of  the  tuberculous  infection;  also  that  a  similar 
change  is  noted  in  comparing  tuberculosis  in  adults  with  spon- 
taneous tuberculosis  in  animals.  While  the  localization  in  the 
cow,  the  other  animal  prone  to  tuberculosis,  is  commonly  on  the 
serous  membranes,  or  in  the  posterior  lobe  of  the  lung,  or  a 


APICAL   COMPRESSION  INCREASES   WITH  AGE  131 

general  tuberculous  pneumonia,  in  man  it  is  almost  universally 
in  the  apex  of  the  lung.  The  relative  increased  anteroposterior 
compression  of  the  apex  which  takes  place  in  man  as  a  result 
of  assuming  the  erect  position  as  compared  with  the  four-legged 
mammals  is  shown  in  Fig.  20. 

From  the  anatomical  facts  here  presented,  it  can  be  seen  that 
while  the  lung  is  growing  and  increasing  in  size;  and,  as  a 
whole,  is  becoming  functionally  more  and  more  active,  the 
growth  and  activity  of  the  lower  portions  far  outstrip  the  up- 
per portions;  in  fact,  wliile  the  lung  is  growing,  the  upper  por- 
tions of  the  bony  thorax  are  flattening,  and  relatively  decreasing 
in  size. 

The  effect  of  this  flattening  of  the  upper  portion  of 
the  chest  at  a  time  when  the  lung  as  a  whole  is  increasing  in 
size,  is  an  ever  increasing  compression  of  the  underlying  apical 
tissue  and  a  relative  decrease  in  the  total  volume  of  the  upper 
portion  of  the  lungs  as  compared  .with  the  lower  portion;  also 
a  squeezing  together  of  the  lung  tissue  of  this  portion,  a  nar- 
rowing of  the  lymph  spaces  and  air  cells  and  a  decreasing  of 
the  respiratory  movement  with  its  consequent  retarding  of  blood 
and  lymph  flow.  The  relative  and  actual  decrease  in  the  amount 
of  lymph  coursing  in  the  apical  lesion  may  also  be  a  factor  in 
reducing  the  resistance  to  infection.  "Whereas  the  flow  of  blood 
and  lymph  is  more  or  less  the  same  in  all  portions  of  the  lung 
in  the  child,  it  is  embarrassed  in  the  apex  of  the  adult.  Conse- 
quently, in  the  child,  infection,  particularly  of  hematogenous 
origin,  which  is  the  most  common  mode  of  metastatic  infection, 
may  occur  in  any  part  or  organ  of  the  body  or  any  portion  of 
the  pulmonary  tissue  where  a  capillary  is  narrowed  or  retarda- 
tion of  the  blood  flow  is  sufficient  to  permit  implantation  of 
bacilli  to  take  place;  and  is  about  as  likely  to  occur  in  one  place 
as  another.  In  the  adult,  on  the  other  hand,  the  apex  of  the 
lung,  which  seems  mechanically  predisposed  by  its  embarrass- 
ment and  its  lessened  motion  and  its  retarded  lymph  and  blood 
flow,  is  the  usual  seat  of  infection.  In  the  early  years  of  life  the 
bony  thorax  grows  faster  than  the  lungs  themselves6  which  fact 
removes  the  element  of  compression  which  is  so  important  in 
increasing  the  predisposition  of  the  apex  in  adults. 


"Hermann  Pfliiger's  Archives,  vol.  xx,  1879. 


132  FACTORS   WHICH  PREDISPOSE   TO  TUBERCULOSIS 

It  is  interesting  to  note  that  these  changes  in  the  contour  of 
the  chest  take  place  at  the  same  time  that  pulmonary  tubercu- 
losis begins  to  assume  a  relatively  greater  importance,  as  com- 
pared with  the  meningeal,  peritoneal,  and  other  forms  which 
are  more  common  in  early  years.  Clinical  pulmonary  tubercu- 
losis does  not  become  an  extremely  common  disease  until  after 
the  second  decade;  and  this  term  of  years  between  early  child- 
hood when  infection  is  occurring,  and  adult  life  when  clinical 
tuberculosis  manifests  itself  in  the  pulmonary  apex,   marks  a 


Fig.  21. — Illustrating  schematically  the  movements  of  the  various  portions  of  the  lung. 
The  degree  of  motion  is  indicated  according  to  the  shading — the  darker  the  portion,  the 
less  the  motion.      (Tendeloo.) 

time  in  the  life  of  the  child  when  it  should  show  a  natural  re- 
sistance and  is  also  the  time  when  the  child  which  has  become 
already  infected  with  the  tubercle  bacillus,  is  best  protected 
by  the  specific  immunity  which  it  has  developed. 

Consideration  of  the  predisposition  of  the  apex  of  the  adult 
lung  to  tuberculous  infection  has  called  forth  a  great  deal  of 
discussion  and  many  theories;  but,  for  the  most  part,  the  sug- 
gested theories  have  been  based  on  anomalies  rather  than  on 
natural  anatomic  and  physiologic  considerations. 


APICAL   ANOMALIES   AND   PULMONARY   INFECTION 


13; 


The  theory  of  Freund  that  ossification  of  the  first  costal  car- 
tilage and  shortening  of  the  first  rib  through  pressure  upon  the 
apex  predisposes  to   tuberculosis,   likewise   that   of  Kothschild 


Fig.  22. — Illustrating  the  mediastinal  aspect  of  the  right  lung,  which  shows  the  degree 
of  respiratory  movement  at  the  root.  The  crus  of  the  diaphragm  is  indicated  and  its  at- 
tachment to  the  root  of  the  lung  through  the  pericardium  shown.  The  black  lines  show 
the  lung  on  expiration,  the  dotted  lines  on  inspiration.  It  will  be  seen  that  the  motion 
about  the  hilus  is  not  great,  and  that  at  the  apex  is  probably  the  least  of  any  portion 
of  the  lung.      (Keith.) 

in  assuming  that  a  diminution  of  the  manubrio-sternal  angle 
is  a  predisposing  factor,  and  the  furrow  described  by  Schmorl 
over  the  posterior  portion  of  the  apex,  have  called  forth  a  great 
deal  of  discussion.  Against  these  theories  is  the  very  important 
physiologic  fact  that  one  of  the  most  important  inspiratory  acts 
is  the  contraction  of  the  diaphragm  which  enlarges  the  lung  not 
only  in  the  anteroposterior  direction,  but  in  the  superoinf erior  di- 


134  FACTORS   WHICH   PREDISPOSE   TO  TUBERCULOSIS 

Section  as  well.  Keith7  called  attention  to  the  accordion  action 
of  the  interlobular  sulci  of  the  lung  and  the  general  enlarge- 
ment which  takes  place  with  the  contraction  of  the  diaphragm. 

I  regard  the  factors  which  make  the  apex  of  the  lung  especial- 
ly predisposed  to  tuberculous  infection,  as  more  fundamental 
than  the  above  mentioned  theories  would  indicate. 

Apical  Compression  Following  Anatomical  Growth  Slows 
Blood  and  Lymph  Current. — A  key  to  the  situation  lies  in  the 
fact  that  the  apex  of  the  child's  lung  is  not  predisposed  to  in- 

VII  Cerv.  Vert. >•••-*---  — ,,^v, 

,?S8Rj$^WS£    2nd  Rib 
Apex  of  lung, -•-  ~~"v£r?C£vJw^ 

1st  rib  (inspir.)    .-... - — V(^>'<1'0>£bi(p '  \\\VS_v 

1st  rib  (expir.),... ... -Jx^-i\}rtf8^\v\\\\w^ 

Manub.   (inspir.)  .„  . /"Vo^rfmrrtf""^^ 

Manub.   (expir.) yv:^iwNM\>M^  i    TiT^J^V^vV 


1st  man  jt. 

1st  man  jt. 


Lung 

(inspir.) 


I/O 


Fig.  23. — Illustrating  the  action  of  the  first  pair  of  ribs  and  manubrium  in  increasing 
the  area  of  the  lung  during  inspiration.  Showing  that  the  posterior  aspect  of  the  apex  is 
the  portion  subjected  to  least  movement.      (Keith.) 

fection,  while  the  apex  of  the  adult  lung  is  so  predisposed.  The 
solution  of  the  problem  may  be  aided  by  studying  the  anatomic 
and  physiologic  changes  in  the  chest  during  the  period  of 
growth,  and  by  studying  the  action  of  the  inhaled  dust  at  the 
various  age  periods,  as  previously  mentioned. 

To  repeat  the  important  facts  mentioned  elsewhere  in  these 
pages,  if  the  child  inspires  air  contaminated  with  dust  or  soot 
the  particles  do  not  lodge  in  the  pulmonary  tissues  but  pass 
through  to  the  subpleural  lymph  spaces,  and  more  particularly 
to  the  peribronchial  lymph  glands.    In  other  words,  they  follow 

"Further  Advances  in   Physiology,   Edit,   by   Leonard  Hill,    1909. 


FACTORS   FAVORING   APICAL   INFECTION  135 

the  course  of  the  lymph  in  the  lymphatic  channels.  In  the 
adult  lung,  on  the  other  hand,  much  dust  and  soot  is  deposited 
in  the  lung  tissue  itself,  and  in  the  subpleural  spaces,  while  the 
bronchial  glands  are  less  affected.  It  is  further  observed,  in 
the  adult  lung,  that  dust  and  soot  are  deposited  particularly  in 
the  apex  of  the  lung,  while  the  base  is  comparatively  free.  It 
has  been  suggested  that  the  reason  for  the  marked  deposit  of 
soot  in  the  lung  tissue  in  the  adult  is  because,  through  pro- 
tracted exposure,  more  and  more  particles  have  become  deposited 
in  the  lymph  spaces  and  that  these  retard  the  progress  of  others 
taken  in  later.  It  has  also  been  thought  that  there  is  more  or 
less  irritation  and  thickening  of  the  lung  tissue  caused  by  the 
dust  particles  which  prevent  their  rapid  transfer  to  the  lymph 
glands.  Some  have  suggested  that  these  deposits  in  the  tissues 
pet  as  a  predisposing  cause  to  the  localization  of  the  tubercle 
bacillus. 

Tendeloo  particularly,  has  insisted  that  the  principal  factor 
in  predisposing  the  apex  to  tuberculosis  is  the  fact  that  there  is 
a  lessened  motion  of  the  lung  in  this  area  and  consequently  a 
retarded  lymph  and  blood  flow.  This  is  shown  in  Figs.  20,  21, 
22,  and  23.  This  is  a  very  important  consideration  in  any  theory 
that  is  offered.  Its  effect  can  be  seen  in  the  distribution  of  the 
deposits  of  dust  and  soot  in  the  lung  of  the  child  as  compared 
with  the  lung  of  the  adult,  and  its  influence  on  the  implanta- 
tion  of  tubercle  bacilli  must  be  equally  important. 

Critical  Examination  of  Theories  of  Freund,  Schmorl  and 
Rothschild. — I  have  endeavored  to  offer  an  anatomic  and  physi- 
ologic explanation  for  the  fact  that  the  apex  of  the  lung  of 
the  adult  is  predisposed  to  infection,  but  I  now  wish  to  take 
up  the  matter  at  this  point  and  discuss!  it  in  relationship  to 
Freund 's  theory,  which  has  received  so  much  attention  during 
recent  years.  With  Freund 's  theory  we  must  also  class  the 
theories  of  Schmorl,8  Birch-Hirschfeld9  and  Rothschild10  because 
they  are  all  closely  related. 


8Zur  Frage  der  beginnenden  Lungentuberkulose,  Mtinchener  medicinische  Wochen- 
schrift,  1901,  No.  SO. 

9Birch-Hirschfeld:  tiber  den  Sitz  und  die  Entwicklung  der  primaren  Lungentuber- 
kulose,  Deutsches  Archiv  fur  klinische  Medicin,  Bd.  64,  1899;  Ibid.,  Des  erste  Stadium 
der  Lungenschwindsucht,  Bericht  Tuberkulosekongress,  1899. 

10Ober  die  physiologische  und  pathologische  Bedeutung  des  sternalkinkels,  XVIII  Kon- 
gress  fur  inner  Medicin,  Karlsbad,  1899. 


136  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

Freund11  published  his  first  articles  with  reference  to  anomalies 
of  the  upper  aperture  of  the  thorax  as  factors  in  the  causation 
of  tuberculosis  in  1858  and  1859,  but  his  theories  were  unnoticed 
for  forty  years.  No  interest  was  taken  in  them  until  Birch- 
Hirschfeld  published  his  paper  with  reference  to  the  peculiar- 
ities of  the  post  apical  bronchus  and  its  relationship  to  tubercu- 
losis and  Schmorl  brought  out  the  idea  of  the  bronchi  being  com- 
pressed by  the  furrows,  which  are  produced  by  the  upper  ribs 
encroaching  upon  the  lung. 

It  was  then  that  Freund12  himself  revived  his  previously  sug- 
gested theories  and  with  the  aid  of  his  pupils  made  for  them 
a  prominent  place  in  the  literature  of  tuberculosis. 

These  publications  created  new  interest  in  the  anatomo- 
pathologic  conditions  surrounding  the  apex  of  the  lung  which 
during  recent  years  have  assumed  great  importance  in  the  dis- 
cussion of  the  question  as  to  why  the  apex  of  the  lung  is  pre- 
disposed to  tuberculosis. 

The  discussion  of  this  subject  by  Hart13  and  by  Hart  and  Har- 
rass,14  and  Bacmeister15  are  extremely  important  and  set  forth 
in  a  clear  manner  the  arguments  in  favor  of  these  predisposing 
factors. 

As  representing  Hart's  most  recent  discussion  I  will  translate 
a  quotation  from  his  article  in  Bei-heft  No.  11,  zur  Medizinischen 
Klinik,  1912,  as  given  by  Martius16  in  a  recent  discussion  of  this 
subject. 

"  'The  upper  aperture  of  the  thorax  which  is  formed  by  the  first 
ribs  and  vertebra  and  sternum  is  heart-shaped  in  form.  On 
either  side  of  the  vertebra  are  the  apices  of  the  lungs  .which  are 
surrounded  by  the  bony  portions  of  the  first  ribs.  The  costal 
ring  departs  from  the  horizontal  in  such  a  way  that  while  the 
apices  of  the  lungs  are  about  on  a  level  with  the  junction  of  the 


uBeitrage  zur  Histologic  der  Rippenknorpel  in  normalen  und  pathologischen  Zus- 
tanden,  Breslau,  1858;  also  Der  Zusammenhang  gewisser  Eungenkrankheiten  mit  pri- 
maren  Rippenknorpelanomalien,   Erlangen,   1859. 

^Thoraxanomalien  als  Predisposition  zur  Lungenphtliise  und  Emphysem,  Verhand- 
lungen  des  Berliner  medizinische   Gesellschaft,   Nov.   27,    1901. 

13Die  mechanische  Disposition  der  Eungenspitzen  zur  Tuberkulosen  Phthise,  Stuttgart, 
1906. 

14Der  Thorax  phthisicus,   eine  anatomisch-physiologische   Studie,    Stuttgart,    1908. 

15Entstehung  und  Verhuetung  der  Eungenspitzen  Tuberkulose,  Deutsche  medizinische 
Wochenschrift,    1911,   Nr.    30. 

16Handbuch  der  Tuberkulose,  Brauer,  Schroder  und  Blumenfeld,  vol.  i,  1914,  p.  409. 


EFFECT    OF   FIRST    COSTAL   RING    ON    RESPIRATION  137 

first  rib  with  the  vertebra,  the  anterior  end  of  the  first  rib  is  2]/2 
cm.  below  the  apex.  In  contrast  to  all  of  the  other  true  ribs  we 
find  that  the  first  costal  cartilage  has  no  articulation  with  the 
sternum.  In  its  place  there  is  a  short  broad  cartilaginous  con- 
nection, whose  union  is  made  secure  by  the  special  firm  consist- 
ency of  the  cartilage.  On  inspiration  the  cartilage  takes  upon 
itself  a  spiral  action  of  such  a  nature  that  the  motion  produces 
a  strong  tension,  the  release  of  which  permits,  or  mechanically 
forces  the  costal  rings  to  return  to  the  position  of  expiration. 
The  first  costal  ring  itself  is  elevated  during  inspiration,  its 
position  approaching  the  horizontal,  but  it  produces  no  widen- 
ing of  the  upper  aperture.  On  forced  inspiration,  even,  the 
respiratory  movement  of  the  upper  aperture  is  also  relatively 
small  in  comparison  with  that  of  the  remaining  ribs,  which 
gradually  increases  toward  the  base  and  whose  elevation  and 
elastic  expiratory  motion  is  favored  by  their  free  articulation 
with  the  vertebrae,  their  long  elastic  cartilages,  as  well  as  their 
articulation  with  the  sternum;  yet,  in  spite  of  this  the  function 
of  the  first  costal  ring  is  of  much  greater  importance  in  the 
respiratory  movement  than  that  of  all  the  others. 

"  'The  respiratory  motion  of  the  lungs  is  regulated  by  a  law 
which  has  been  suggested  by  Tendeloo,  that  every  portion  of  the 
lung  is  dependent  functionally  upon  that  portion  of  the  thorax 
overlying  it.  According  to  this,  while  distension  of  single  por- 
tions of  the  lung  is  of  influence  upon  the  amount  of  the  entire 
volume  of  respiratory  air,  compensatory  balances  for  local  loss 
taking  place,  one  portion  of  a  lung  is  never  able  to  influence  the 
functional  activity  of  a  distant  portion  in  such  a  way  that  the 
movement  of  the  lung  tissue  in  all  places  is  uniformly  the  same. 
The  alveoli  of  the  apices  of  the  lung  are,  in  a  general  physiologic 
sense  dilated  to  a  lesser  degree  during  inspiration;  and  the  total 
pulmonary  tissue  experiences  a  weaker  expansion  than  is  the 
case  in  the  remaining  portions  of  the  lung.  Only  by  a  forced 
pronounced  costal  breathing  does  the  lung  apex  show  a  strong 
respiratory  motion.  By  adjusting  respiration  to  the  minimum 
demand  of  oxygen,  as  in  the  usual  moderately  shallow  thoracic 
breathing,  a  complete  filling  of  the  apices  of  the  lungs  seldom 


138  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

takes  place;  consequently,  under  normal  conditions,  the  respira- 
tory motion  of  the  upper  part  of  the  lung,  when  compared  to  the 
lower  portion  of  the  lung,  that  is,  the  prevailing  relative  func- 
tional activity,  is  decidedly  small,  as  has  been  shown  by  Riegel. ' 

"Under  normal  physiologic  conditions,  this  aeration  is  suf- 
ficient, but,  under  pathologic  conditions,  it  is  different. 

"  'The  important  fact  of  our  new  teaching  is  that  in  almost 
every  adult  person  suffering  from  tuberculosis  there  is  an  an- 
atomical departure  from  the  normal  in  the  upper  aperture  of  the 
thorax.  At  one  time  this  takes  the  form  of  abnormal  shorten- 
ing of  the  cartilage  as  described  by  Freund;  again,  in  an  ar- 
rested development  of  malformation  of  the  bony  portions  of  the 
rib ;  and,  still  again,  in  a  combination  of  both  of  these  condi- 
tions. Sometimes  the  changes  are  symmetrical  and  sometimes 
asymmetrical,  but  always  produce  the  same  effect,  differing  on- 
ly in  degree;  namely,  the  transformation  of  the  aperture  from 
the  oval  heart-shaped  form  into  a  more  long  oval  form,  as  is  the 
type  in  animals  and  in  man  during  the  fetal  stage.  In  the 
formation  of  this  pathological  aperture  the  ribs  do  not  run  in  a 
gentle  curve,  but  more  directly  forward  to  the  sternum,  conse- 
quently, the  transverse  diameter  is  shortened;  but,  what  is  of 
paramount  importance,  there  is  present  a  greater  or  lesser  eon- 
traction  of  the  posterior  para-vertebral  areas  in  which  the  apices 
of  the  lungs  lie  and  move. 

"  'The  upper  costal  ring  which  shows  these  pathological 
changes  can  only  be  considered  as  a  whole  and  in  its  relation- 
ship to  the  entire  thorax.  One  must  recognize  that  not  only  its 
pathological  configuration,  but  the  degree  of  narrowing  of  the 
superior  aperture  of  the  thorax  is  extremely  variable,  and  also 
that  it  depends  somewhat  upon  the  condition  of  the  neighbor- 
ing parts  (vertebra).  He  must  also  see  that  the  anatomical 
changes  of  form  and  changes  of  position  of  the  aperture  and  its 
relationship  to  the  expansion  of  the  apices  emphasizes  any 
anatomic  functional  disturbances  that  might  be  present.  This 
disproportion  produces  a  permanent  pressure  upon  the  pulmon- 
ary tissue  of  the  apex.  The  consequence  of  this  continuous  pres- 
sure of  the  narrow  and  immobile  costal  ring,  which  is  elevated 
only  a  little  or  not  at  all  through  the  respiratory  motion,  is 
an  injury  of  the  lung  tissue  which  is  thus  encircled.    This  makes 


ANOMALIES   OF   SUPERIOR   THORACIC   APERTURE  139 

itself  manifest  subapically  by  means  of  a  very  marked  furrow 
in  which  the  ribs  lie.  In  the  interior  of  the  lung,  however,  the 
small  bronchi  are  compressed  in  such  a  manner  that  the  apical 
bronchial  systems  give  one  the  impression  of  being  stunted  in 
growth.  Whoever  has  seen  these  two  changes  which  Schmorl 
and  Birch-Hirschfeld  first  considered  worthy  of  description,  must 
be  completely  convinced  of  their  dependence  upon  the  changes 
in  the  first  costal  ring.  Whoever  opposes  this  has  never  seen 
these  changes  in  the  pulmonary  apices  and  forgets  that  in  a 
large  material  of  thousands  of  autopsies  only  an  accident  could 
bring  it  before  one 's  eyes,  even  though  he  were  continually  look- 
ing for  it,  because  primary  tuberculosis  quickly  destroys  the 
original  anatomical  relations. 

"  'What  we  must  conclude  from  these  positive  anatomical 
facts  is  plain.  The  mechanical  functional  disturbance  of  the 
upper  aperture  of  the  thorax  leads  to  an  interference  with  the 
ventilation  of  the  apical  tissue,  and,  secondarily,  to  an  embar- 
rassment of  the  blood  and  lymph  flow,  both  of  which  are,  in  a 
large  measure,  dependent  upon  the  respiratory  movement  of  the 
pulmonary  tissue.  The  interference  with  the  ventilation  of  the 
apices  is  not  only  logically  explained  by  the  functional  depend- 
ence of  the  pulmonary  apices  upon  the  respiratory  movements 
of  the  upper  aperture  of  the  thorax,  and  the  specially  unfavor- 
able conditions  which  result  during  quiet  respiration  from  the 
peculiar  course  of  the  apical  bronchi;  but  can  also  be  directly 
proved  upon  the  living  through  shadows  indicative  of  thicken- 
ing of  the  tissues  shown  rontgenologically,  which  indicates 
partial  or  complete  atelectasis  or  a  later  stage  of  collapse  in- 
duration, and  also  on  the  cadaver  by  an  increased  deposit  of 
carbon  in  the  apical  tissues. 

"  'Arnold  has  experimentally  shown,  and  it  is  likewise  a  com- 
mon postmortem  experience,  that  foreign  particles  are  usually 
lodged  in  the  neighborhood  of  thickenings  in  the  tissues,  also 
in  the  tissues  which  do  not  take  full  part  in  the  respiratory  move- 
ment. I  (Hart)  have  especially  called  attention  to  the  fact  that 
the  initial  tuberculous  apical  lesion  does  not  correspond,  as  a 
rule,  to  the  sub-apical  pressure  furrow  and  the  costal  ring,  but 
occurs  in  the  tissues  which  are  partially  atelectatic. 

"  'From  a  physical  standpoint  the  likelihood  of  tubercle  bacilli 


140  FACTORS   WHICH   PREDISPOSE   TO  TUBERCULOSIS 

settling  in  the  apical  tissues  is  also  increased  by  the  aperture 
anomalies.  The  reason  that  the  bacilli  are  able  to  exercise  their 
specific  injurious  influence  is  because  of  the  increase  of  the  bio- 
chemical susceptibility  in  the  tissues,  in  consequence  of  the  dis- 
turbance in  the  blood  and  lymph  circulation  which  causes  them 
to  lose  their  natural  resistance  to  the  tubercle  bacillus  in  conse- 
quence of  poor  nutrition.  That  such  a  thing  exists  no  one  can 
doubt  who  recognizes  that  almost  every  man  comes  in  contact 
sometime  with  tubercle  bacilli,  and  that  they  penetrate  into  the 
lung,  usually  in  comparatively  small  numbers,  nevertheless  he 
becomes  ill  and  suffers  either  from  progressive  tuberculosis  or 
from  some  of  the  less  virulent  forms  of  infection.  It  has  also 
been  shown  that  the  farther  the  upper  aperture  departs  from  the 
normal  the  quicker  the  process  in  the  pulmonary  apex  spreads 
after  infection  has  occurred,  and  the  more  rapid  does  it  spread. 
On  the  other  hand,  the  susceptibility  of  the  tubercle  virus,  the 
individual  disposition,  is  the  same  without  reference  to  the  way 
the  bacillus  enters  the  body,  whether  by  the  air,  the  blood  or 
lymph  passages.  The  physical  opportunity  and  the  biochemical 
susceptibility  is  the  same.  Aside  from  this  the  conditions  under 
which  the  tuberculous  process  spreads  in  the  inferior  portions 
of  the  lung  and  in  other  organs  has  nothing  to  do  with  the  ques- 
tion of  disposition.'  " 

Martius  asks  the  question:  how  is  this  theory  to  be  harmon- 
ized with  the  work  of  Ghon  which  shows  that  in  children  the 
apex  does  not  show  a  special  disposition  to  tuberculosis?  And 
answers  it  by  quoting  from  Hart  as  follows: 

"In  children  the  fixation  of  the  upper  thoracic  aperture,  which 
is  the  result  of  a  gradual  development,  has  not  yet  taken  place. 

"With  the  completion  of  the  growth  of  the  body,  every  func- 
tional disproportion  between  the  development  of  the  thoracic 
aperture  and  the  development  of  the  pulmonary  apex  becomes 
exaggerated,  and  of  greater  importance  the  wider  the  departure 
from  the  normal.  At  this  time  both  the  physical  conditions  and 
the  biological  susceptibility  favor  the  implantation  and  growth 
of  the  bacillus  no  matter  when  or  in  what  manner  it  enters. 
The  morbidity  from  tuberculosis  increases  with  great  sudden- 
ness (explosionartig)  at  the  end  of  the  second  and  beginning  of 
the  third  decade  and  the  disease  does  not  heal  but  goes   on 


CRITICISM   OF  FREUND'S   THEORY  141 

making  an  almost  continuous  selection  from  all  of  those  who 
are  predisposed.  Now  and  then  someone  will  escape  infection 
with  the  tubercle  bacillus  and  its  consequences;  some,  by  pos- 
sessing relatively  favorable  conditions  in  the  pulmonary  tissue 
are  enabled  to  develop  a  resistance  to  the  enemy,  which  lasts 
for  a  long  time,  probably  through  life ;  in  all  severe  cases,  how- 
ever, the  battle  is  decided  and  the  fate  of  the  individual  sealed 
from  the  beginning." 

The  weak  point  in  these  theories  lies  in  failing  to  grasp  that 
any  compression  caused  by  a  primarily  shortened  rib  or  nar- 
rowed aperture  or  changed  manubrio-sternal  angle,  is  only  a 
part  of  the  general  compression  which  occurs  in  the  upper  por- 
tion of  the  thorax  in  the  adult,  as  compared  to  the  child,  thus 
basing  infection  of  the  apex  upon  anomalies  instead  of  natural 
anatomic  and  physiologic  factors. 

There  should  be  added  to  this  excellent  recent  description 
given  by  Hart,  some  of  the  ideas  which  were  originally  enunciated 
by  Freund,  which  are  not  here  mentioned. 

In  Freund 's17  early  description  in  discussing  the  ankylosed 
rib,  he  particularly  calls  attention  to  the  altered  condition  of 
scaleni  muscles  in  the  following  language: 

"In  many  patients  who  are  suffering  from  beginning  chronic 
tuberculosis  of  the  apex  of  the  lungs,  one  finds  pathological 
changes,  especially  in  the  first  costal  cartilage,  this  change 
being  an  ossification.  The  bony  change  does  not  proceed  from 
an  inflammation  of  the  pleura,  for  it  usually  begins  first  on  the 
edges,  then  on  the  outer  surface  of  the  rib,  and  at  last  on  the 
inner  surface,  and  all  takes  place  without  the  pleura  being 
changed.  This  also  occurs  in  beginning  tuberculosis  where  the 
pleura  is  not  yet  involved.  Under  these  conditions  one  always 
sees  strong  antagonistic  development  of  the  scaleni  whose  point 
of  insertion  on  the  rib  often  shows  an  exceptional  size." 

My  recent  clinical  observations18  on  the  presence  of  reflexes 
caused  by  inflammation  within  the  lungs  shows  that  these  mus- 
cles are  thrown  into  definite  contraction  (spasm)  reflexly  from 


17Beitrage  zur  Histologie  der  Rippenknorpel  in  normalen  und  pathologischen  Zus- 
tanden,    Breslau,    1858,   quoted   by   Hart. 

18Muscle  Spasm  and  Degeneration  in  Intrathoracic  Inflammations  and  Light  Touch 
Palpation,  C.  V.  Mosby  Co.,  St.  Louis,  1912;  and  Inspektion,  Palpation,  Perkussion  and 
Auskultation  bei  der  Fruhdiagnose  der  Lungentuberkulo.se,  Brauer's  Beitrage  zur  Klinik 
Tuberkulose,  vol.   xxxiii,   part    1,    1915. 


142  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

the  disease  within  the  lung,  and  that  what  Freund  described  here 
was  not  hypertrophy  due  to  muscles  pulling  against  an  anky- 
losed  rib,  but  a  reflex  contraction  due  to  the  pulmonary 
inflammation. 

It  is  further  necessary  to  bear  in  mind  that  we  have  sensory, 
motor  and  trophic  reflexes  dependent  upon  this  pulmonary  ir- 
ritation. As  evidences  of  the  trophic  reflex  we  have  the  follow- 
ing phenomena:  wasting  of  the  skin,  subcutaneous  tissue  and 
muscles,  and  dry  arthritis  of  the  joints,  particularly  the  shoul- 
der joint.  Knowing  that  the  bony  structures  and  the  joints  are 
supplied  by  the  same  nerves  as  the  tissues  over  them  (Piersol) 
we  are  justified  in  drawing  the  inference  that  trophic  disturb- 
ances might  also  show  in  the  bones  and  cartilages.  While  short- 
ening of  the  first  rib  in  some  cases  might  be  congenital  or  might 
be  due  to  some  early  disease  of  the  bone  or  cartilage,  interfer- 
ing with  its  proper  development;  yet  we  must  not  lose  sight  of 
the  trophic  disturbance  which  could  be  exerted  reflexly  upon 
these  structures  by  inflammation  within  the  thorax,  particularly 
of  the  lungs.  It  is  extremely  suggestive  in  this  connection  that 
Hart  should  say:19  "Freund  attempted  to  carry  this  in- 
terference with  the  development  of  the  first  costal  cartilage  back 
to  the  time  of  childhood,  even  to  the  fetal  epoch,  but  I,  person- 
ally, have  in  no  case,  either  in  a  child  or  in  a  fetus  been  able  to 
find  unquestionable  symmetrical  shortening  of  the  first  costal 
cartilage  as  a  result  of  some  prenatal  interference  with  nutri- 
tion of  the  bone  and  cartilage."  That  tuberculous  infection  has 
a  decided  reflex  trophic  influence  on  these  structures  we  know 
from  clinical  experience  and  are  led  to  infer  from  the  analysis 
of  Hart's  own  statistics;  and,  that  it  could  cause  ankylosis  of 
the  first  costosternal  articulation  by  reflex  trophic  action  and 
the  diminished  motion  which  follows  infection  is  quite  clear. 

At  this  point  I  desire  to  quote  from  papers  by  Stiller,  Schiele, 
and  Eevesz,  because  they  have  important  bearing  upon  the  re- 
lationship of  compression  of  the  upper  aperture  of  the  thorax 
to  tuberculosis,  also  upon  the  relationship  between  calcification 
of  the  first  costal  cartilage  and  the  tuberculous  infection. 

Stiller20  questions  the  importance  of  the  thorax  phthisicus  as 


19loc.  cit. 

20Der  tuberkulose  Thorax  phthisicus  und  die  tuberkulose  Disposition,  Berliner  klinische 
Wochenschrift,   1912,  No.  3. 


CRITICISM   OF  FREUND'S   THEORY  143 

being  a  predisposing  cause  of  tuberculosis  and  also  claims  that 
the  anomalies  of  the  upper  aperture  of  the  thorax  are  identical 
with  his  thorax  asthenicus.  He  does  not  consider  that  the  early 
ossification  of  the  first  costal  cartilage  upon  which  Freund  and 
Hart  lay  so  much  weight  is  more  than  one  factor  among  many. 

Schiele21  lays  particular  stress  upon  the  degree  to  which  the 
rib  departs  from  the  horizontal,  claiming  that  the  greater  the 
angle  of  departure  of  the  upper  aperture  in  asthenic  individuals, 
the  greater  the  interference  with  the  function  of  the  organs 
within.  He  looks  upon  the  early  ossification  of  the  first  costal 
cartilage  as  not  being  a  cause  but  a  consequence  of  apical  tuber- 
culosis and  considers  that  it  is  due  to  a  diminution  of  the  in- 
tensity of  the  respiratory  movement.  He  says  that  thorax 
phthisicus  is  not  inherited  but  developed  after  birth. 

Revesz22  reports  the  examination  of  22  individuals  with  marked 
thorax  asthenicus  (Stiller)  and  found,  according  to  the  method 
of  Harris,  a  shortening  of  the  firsts  costal  cartilage  in  every  in- 
stance. For  controls  he  examined  11  people  with  normal  chests 
and  did  not  find  a  shortening  of  the  first  rib  in  a  single  instance. 
In  22  asthenic  individuals  he  found  only  4  in  whom  there  was 
no  trace  of  tuberculosis.  In  these  4  there  was  also  no  ossification 
in  the  first  costal  cartilage  in  a  single  instance.  In  7  of  the  re- 
maining 18  who  had  a  tuberculous  infection,  the  apex  of  the 
lung  was  normal,  the  infection  being  in  the  peribronchial  glands. 
In  these  7  cases  ossification  of  the  first  costal  cartilage  was  also 
wanting.  In  the  remaining  11  cases  which  showed  pulmonary 
tuberculosis  radiologically,  calcification  of  the  first  costal  car- 
tilage was  found,  therefore  Revesz  draws  the  conclusion  that  it  is 
not  the  asthenia  but  the  tuberculosis  which  produces  the  calci- 
fication in  the  costal  cartilage  and  that  this  is  not  a  predisposing 
cause  but  a  result  of  tuberculosis.  He  further  states  that  there 
was  no  evidence  of  ossification  in  the  first  costal  cartilage  in 
any  of  the  11  controls,  and,  further,  that  ossification  of  the  firsl 
costal  cartilage  has  not  been  found  in  a  single  instance  in  the 
Roentgen  Institute   of  the  University   of  Budapest  in  a   young 


21Die  Neigung  der  oberen  Thoraxapertur,  Zeitschrift  fur  klinische  Medicin,  1912,  vol. 
lxxvi,   parts   5   and  6. 

22Thoraxphthisicus  und  Thorax  asthenicus,  Gyogyaszat,  1912,  no.  5;  Internationales 
Centralblatt  fur  die  gesamte  Tuberkulose-Forschung,   1912,  VII,  Jhg.,  no.  2,  p.  67. 


144  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

individual  who  did  not  also  at  the  same  time  have  pulmonary 
tuberculosis.  On  the  contrary,  not  a  single  instance  of  pro- 
gressive tuberculosis  has  been  examined  which  did  not  show 
an  ossification  of  the  first  costal  cartilage. 

Of  the  400  bodies  which  he  examined  postmortem  with  refer- 
ence to  shortening  of  the  first  costal  cartilage,  Hart  found  in 
114  or  281/2  per  cent  that  they  were  shorter  than  normal.  Of 
the  114  bodies  showing  changes  in  the  first  rib,  104  or  26  per 
cent  of  all  suffered  from  tuberculosis  of  the  pulmonary  apices 
and  78  or  19^2  Per  cent  of  the  total  number  suffered  from  pro- 
gressive tuberculosis.  He  states  that  this  shortening  of  the  rib 
has  a  definite  effect  in  producing  progressive  tuberculosis  because 
78  or  62.4  per  cent  of  the  125  progressive  cases  found  in  the  total 
400,  showed  abnormal  shortening  of  the  first  costal  cartilage. 
How  it  could  do  this  is  difficult  to  explain.  The  suggestion  of 
deficient  nutrition  does  not  satisfy.  This  fact  is  a  great  deal 
more  suggestive  to  me  of  progressive  tuberculosis  being  a  cause 
of  the  changes  in  the  rib  and  cartilage,  as  I  shall  discuss  later. 
According  to  the  theory  which  justifies  artificial  pneumothorax, 
compression  should  favor  quiescence  rather  than  progressive  tu- 
berculosis. 

In  Hart's  45  cases  which  were  intimately  associated  with  tu- 
berculosis in  the  family  34  or  75^2  per  cent  showed  shortening 
in  one  or  both  cartilages,  a  larger  percentage  than  in  non-tuber- 
culous families.  The  fact  that  tuberculosis  shows  in  a  larger 
percentage  of  those  who  come  from  tuberculous  families  than 
those  who  come  from  non-tuberculous  families  and  that  shorten- 
ing of  the  cartilage  is  also  more  common  in  these,  would  indicate 
that  this  anomaly  seems  to  be  increased  with  increased  danger 
of  infection.  The  infection  also  extends  to  the  lungs  more  often 
and  earlier  in  children  who  associate  with  open  tuberculosis  in 
early  life  because  of  the  greater  exposure  and  more  massive  in- 
fection; therefore,  the  reflex  trophic  effect  produced  on  the  costal 
cartilages  and  the  effect  of  lessened  motion  would  be  far  more 
apparent,  and  we  would  also  expect  this  anomaly  to  be  more 
common  if  it  were  a  result  of  the  disease. 

It  is  well  known  that  tuberculosis  of  the  lungs  is  not  common 
in  childhood  and  that  if  it  occurs  it  usually  goes  rapidly  to  a 
fatal  termination;  nevertheless,  the  more  massive  the  infection, 


REFLEX    TROPHIC     CHANGES    IN    FIRST     COSTAL     RING  145 

the  greater  the  danger  of  pulmonary  metastases  occurring.  This 
explains  the  fact  that  more  pulmonary  infection  is  found  in  the 
children  of  families  where  there  has  been  open  tuberculosis  than 
in  the  families  where  less  danger  exists.  Mediastinal  glands 
produce  a  trophic  reflex  affecting  the  superficial  structures  the 
same  as  the  lungs.  With  the  more  massive  infection,  and  the 
probability  of  earlier  extension  to  pulmonary  tissue  and  the  eon- 
sequent  greater  inflammatory  reaction,  we  are  led  to  suspect  a 
more  marked  trophic  reflex  in  the  children  of  tuberculous  fam- 
ilies than  in  those  free  from  such  association.  The  greater  per- 
centage of  trophic  change  in  the  cartilages  therefore,  is  not  sur- 
prising. 

The  most  suggestive  part  of  Hart's  statistics  to  me,  however, 
is  the  comparative  relationship  between  the  incidence  of  infec- 
tion and  the  anomalies  of  the  first  costal  ring.  He  found  that 
254  or  63.4  per  cent  of  the  400  bodies  examined  postmortem 
showed  apical  infection,  but  only  114  or  28V2  per  cent  showed 
pathological  changes  in  the  costal  cartilage ;  and  that,  further, 
in  78,  or  62.4  per  cent  of  the  125  cases  of  progressive  tuber- 
culosis, shortening  of  the  first  rib  was  found.  This  would  in- 
dicate that  these  changes  in  the  costal  cartilage  are  not  par- 
ticularly related  to  tuberculous  infection,  but  that  they  are  re- 
lated to  active  progressive  tuberculosis.  We  know  that  active 
progressive  tuberculosis,  as  a  rule,  is  a  chronic  disease  and  as 
such  would  have  greater  opportunities  to  produce  trophic  changes 
in  the  costal  cartilage  than  would  abortive  infections,  such  as 
those  which  are  so  commonly  found  in  the  apices  of  the  lungs, 
but  which  never  go  on  to  active  development.  Likewise,  active 
progressive  tuberculosis  would  favor  ankylosis  of  the  costo-sternal 
articulation  by  the  reduced  respiratory  excursion  which  accom- 
panies active  pulmonary  disease. 

These  anomalies  cannot  be  discussed  except  by  taking  into 
consideration  the  mechanics  of  respiration. 

Tendeloo23  in  his  careful  study  of  the  mechanics  of  respi- 
ration has  shown  us  that  the  air  cells  in  different  portions  of  the 
lungs  are  expanded  unequally.  There  is  only  a  slight  expan- 
sion of  those  near  the  hilus,  a  little  greater  in  those  at  the  apex, 
and  still  a  little  greater  in  the  para-vertebral  area  of  the  su- 


^Studie  Uber  die  Ursachen  des  Lungenkrankheiten,  Wiesbaden,  1901. 


146  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

perior  lobe.  These  three  areas  of  the  lung  are  particularly  those 
of  diminished  respiratory  movement.  The  air  cells  of  the  lower 
lobe  are  subject  to  greater  inspiratory  effort  and  consequently 
are  dilated  more.  Two  forces  must  be  considered  in  respira- 
tion. One,  the  costal  rings  and  the  other  the  diaphragm.  The 
costal  rings  are  so  attached  to  the  vertebral  column  and  the 
sternum  that  during  inspiration  not  only  is  the  anterior  end 
raised  but  the  lateral  portion  of  the  ribs  is  also  elevated  (this 
is  especially  true  of  the  lower  ribs),  thus  increasing  the  trans- 
verse as  well  as  the  anteroposterior  diameter  of  the  chest.  The 
axes  of  these  costal  rings  depart  from  the  horizontal  in  differ- 
ent degrees.  While  the  first  costal  ring  departs  only  about  10 
degrees  from  the  horizontal,  the  tenth  departs  nearly  45  de- 
grees as  shown  in  Fig.  18.  Resulting  from  this,  there  is  a  marked 
unequal  movement  of  the  various  portions  of  the  thoracic  wall 
above  and  below,  the  movement  of  the  superior  being  slight 
while  that  of  the  inferior  is  quite  marked.  When  we  add  to  this 
the  contraction  of  the  diaphragm  we  have  another  force  which 
enlarges  the  thoracic  cavity  in  the  vertical  direction  and  which 
exerts  its  greatest  influence  on  the  lower  portion  of  the  lung. 
The  change  in  position  of  the  diaphragm  on  inspiration  and  ex- 
piration amounts  to  from  one  to  two  inches.  Its  contraction 
not  only  lengthens  the  thoracic  cage  but  also  helps  to  force  out 
the  ribs  and  increases  the  transverse  as  well  as  the  anteropos- 
terior diameter  of  the  lower  portion  of  the  chest.  Our  knowl- 
edge of  the  relative  value  of  diaphragmatic  and  costal  breath- 
ing in  air  capacity  is  not  well  established.  Tigerstedt24  says 
relative  to  diaphragmatic  and  costal  breathing  that  we  have  at 
present  but  a  single  measurement  of  the  absolute  value  of  the 
diaphragmatic  as  compared  with  the  costal  enlargement  of  the 
thorax;  namely,  out  of  490  centimeters  of  inspired  air  in  man 
about  320  centimeters  develop  upon  the  elevation  of  the  ribs 
and  only  170  centimeters  on  the  descent  of  the  diaphragm. 

While  we  may  roughly  say  that  the  expansion  of  any  par- 
ticular portion  of  the  pulmonary  tissue  depends  upon  the  mo- 
tion of  the  thoracic  wall  immediately  over  it,  as  suggested  by 
the  law  of  Tendeloo,  quoted  by  Hart,  yet  this  is  not  wholly  true, 


2JText  Book  of  Physiology,   D.   Appleton  &   Co.,  New  York,   1906. 


LOCALIZATION  OF  BACILLI  AND  RESPIRATORY  MOVEMENT  147 

because  the  action  of  the  diaphragm  exerts  its  influence  even  to 
the  apex  of  the  lung  as  shown  by  Keith. 

Keith25  says  that  these  physiological  facts  (referring  to  the 
motion  of  the  pulmonary  tissue  and  the  distention  of  the  air 
cells  in  the  various  parts  of  the  lung)  have  a  very  important 
bearing  upon  the  localization  of  the  tubercle  bacilli  and  the  pre- 
disposition of  the  lung  to  infection.  Tubercle  bacilli  find  most 
favorable  conditions  for  implantation  in  these  areas  of  lessened 
lung  expansion.  This  fact  has  been  used  to  support  the  theory 
of  Freund,  but  it  seems  to  me  that  there  are  many  points  which 
show  that  the  cause  of  the  tendency  for  tubercle  bacilli  to  be 
implanted  in  the  apex  or  the  posterior  aspect  of  the  superior 
lobe  is  more  fundamental  than  shortening  of  the  first  costal  carti- 
lage and  its  compressing  influence  upon  the  pulmonary  tissue. 
If  it  were  due  to  the  compression  from  the  rib  we  would  expect 
to  find  the  implantation  occur  not  posteriorly  where  it  so  often 
does,  but  laterally  where  compression  is  greatest. 

In  reality  the  movement  of  the  first  pair  of  ribs  and  the  manu- 
brium, as  Keith  shows,  expands  particularly  the  anterior  or 
ventrolateral  part  of  the  apex  of  the  lungs,  particularly  that 
part  of  the  lung  in  front  of  the  neck  of  the  first  and  second  pair 
of  ribs,  where  implantation  so  commonly  occurs;  so  it  seems 
to  me  that  since  there  are  other  ways  of  satisfactorily  account- 
ing for  the  ankylosis  of  the  first  costo-sternal  articulation  arid 
shortening  of  the  first  rib  and  costal  cartilage,  and  since  the  im- 
plantation of  bacilli  does  not  occur  where  we  would  expect  it 
to  occur  from  the  nature  of  the  case,  if  it  were  due  to  the  ac- 
tion of  this  first  costal  ring  we  are  forced  to  look  for  some  other 
cause  which  operates  to  favor  apical  infection.  That  this  short- 
ened rib,  where  it  does  occur,  is  a  factor  in  compression,  cannot 
be  denied;  but  it  seems  to  me  more  probable  that  it  is  only  a 
part  of  a  greater  cause  and  not  the  cause  itself.  This  greater 
cause,  I  believe,  is  found  in  the  changes  which  take  place  in 
respiration  as  the  child  grows  in  years  and  adolescence  is  ap- 
proached. 

Habitus  Phthisicns. — This  subject  has  received  attention  from 
many  writers,  particularly  Schliiter.26    There  has  been  described  a 


25Further  Advances  in   Physiology,   Hill,   London,    1909. 
2CDie  Anlage  zur  tuberkulose,  Wien,   1905. 


148  FACTORS   WHICH   PREDISPOSE   TO   TUBERCULOSIS 

certain  form  of  body  which  has  been  thought  to  have  a  predis- 
posing influence  to  tuberculosis;  but,  now  that  we  understand 
the  tuberculous  infection  and  its  effect  upon  the  human  body 
better,  we  know  that  in  many  instances  habitus  pTithisicus  is 
not  a  predisposing  factor  to  tuberculosis  but  a  result  of  tubercu- 
losis. We  further  know  that  while  this  peculiar  build  furnishes 
its  just  proportion  of  victims  to  tuberculosis,  yet  there  is  no 
form  or  shape  of  body  that  is  not  susceptible  to  tuberculous  in- 
fection. Moeller27  says  that  any  practitioner  knows  that  at 
least  three-fourths  of  his  tuberculous  patients  have  a  normally 
built  thorax.  My  own  experience  would  confirm  this  view.  The 
principal  characteristics  of  habitus  pMhisicus  are  a  long  flat- 
tened chest  with  wide  intercostal  spaces,  prominent  clavicles, 
long  thin  neck,  acute  costo-sternal  angle,  winged  scapulas,  with 
a  tendency  to  scoliosis.  The  individual  is  usually  tall  and  has 
weak  musculature.  To  this  has  been  added  more  recently  the 
anomalies  of  the  upper  aperture  of  the  thorax  (Freund)  as  well 
as  that  of  a  floating  tenth  rib.28 

The  Small  Heart. — It  is  necessary  in  dealing  with  the  special 
factors  which  predispose  to  tuberculosis  to  give  attention  to  the 
fact  that  for  many  years  the  size  of  the  heart  has  been  consid- 
ered as  a  causative  factor.  While  I  have  discussed  the  cause  of 
this  more  fully  elsewhere  in  these  pages,  it  is  necessary  to  men- 
tion it  here  in  connection  with  the  subject  under  discussion,  but 
I  would  refer  those  interested  to  the  fuller  discussion  on  page 
301. 

Brehmer  was  convinced  at  the  autopsy  table  that  the  small 
heart  was  present  in  a  large  number  of  tuberculous  subjects  and 
was  convinced  that  it  was  a  predisposing  factor  in  the  produc- 
tion of  the  disease.  He  reasoned  that,  the  heart  being  small, 
the  lungs  were  proportionately  large  for  the  amount  of  blood 
they  received,  consequently,  on  account  of  undernutrition,,  be- 
came diseased.  It  must  be  remembered  in  reading  Brehmer 's 
work  that  his  ideas  were  given  out  in  the  prebacillary  days.  His 
belief  in  the  existence  of  the  small  heart  in  tuberculosis  was 
based  on  12,000  careful  personal  observations. 

It  was  found  that  the  small  heart   existed  not   only  in  the 


27Lehrbuch  der   Lungentuberkulose,   Wiesbaden,    1910. 

28Stiller:    Die   asthenische   Konstitutionskrankheit,    Stuttgart,    1907. 


SMALL    HEART    AND    TUBERCULOSIS  149 

bodies  of  those  who  came  to  autopsy,  as  a  result  of  their  tuber- 
culosis, but  in  those  who  died  of  accidental  death  and  in  whom 
an  early  or  moderately  advanced  infection  Was  found.  In  such 
cases  the  small  heart  was  attributed  to  some  defect  of  develop- 
ment and  was  naturally  considered  as  having  a  causative  rela- 
tionship to  the  disease. 

My  suggestion  for  the  cause  of  the  small  heart  is  a  physiolog- 
ical one.29  It  is  based  upon  the  fact  that  aside  from  the  strength 
of  the  heart  muscle  and  the  elasticity  of  the  vessel  walls,  the 
greatest  accessory  factor  in  the  circulation  of  the  blood  is  the  suc- 
tion action  caused  by  the  inspiratory  act,  which  accompanies  the 
enlargement  of  the  thoracic  cage.  With  every  inspiration  the 
negative  pressure  in  the  thorax  is  increased,  the  vessels  are 
opened  and  the  blood  is  drawn  from  the  systemic  veins  and 
delivered  to  the  heart.  Any  condition  which  interferes  with  in- 
spiration reduces  this  suction  action  and  consequently  causes  less 
blood  to  be  delivered  to  the  heart.  The  heart,  receiving  less 
blood,  contains  less  blood  and  delivers  less  blood  at  each  sys- 
tole. The  result  is  that  it  accommodates  itself  to  the  condition 
and  becomes  smaller. 

The  same  cause  operating,  causes  the  relatively  small  arteries 
which  likewise  have  been  described  as  being  predisposing  to 
tuberculosis. 


29The    Small    Heart   in    Tuberculosis:    A    Physiological    Explanation,    Journal    American 
Medical  Association,  April   17,   1915. 


CHAPTER  VI. 
THE  NERVOUS  SYSTEM  IN  TUBERCULOSIS. 

Psychoses. — The  nervous  system  shows  very  interesting  and 
important  changes  in  tuberculosis.  These  departures  from  the 
normal  affect  the  .nervous  system  at  all  levels,  physico-chemical, 
sensorimotor,  and  psychical.  The  relationship  between  tuber- 
culosis and  insanity  has  long  been  recognized.  The  death  rate 
from  tuberculosis  among  the  insane  of  asylums  is  double  or 
quadruple  that  of  the  general  population.  This  is  not  so  diffi- 
cult to  explain  now  that  we  know  the  frequency  of  infection  in 
the  human  race  and  also  know  that  the  advanced  lesions  of 
later  years  may  be  due  to  renewed  activity  in  old  foci.  The 
lowered  resistance  of  the  insane  can  readily  bring  about  condi- 
tions favorable  to  the  multiplication  of  bacilli ;  and  when  activity 
has  once  started,  the  patient  offers  feeble  resistance  to  the  spread 
of  infection. 

In  some  instances,  on  the  other  hand,  the  tuberculous  process 
with  its  toxins  is  most  likely  the  active  force  in  the  production 
of  insanity.  I  have  seen  several  cases  of  insanity  which  were 
complications  of  active  pulmonary  tuberculosis  in  which  the 
tuberculosis  seemed  definitely  to  be  the  etiological  factor. 

Jessen  is  of  the  opinion  that  diseases  dependent  on  degenera- 
tion of  the  nervous  system  are  more  common  in  tuberculous  fam- 
ilies than  in  the  non-tuberculous. 

A  very  interesting  psychical  disturbance  which  has  come  un- 
der my  observation  on  several  different  occasions  is  that  of 
double  personality.  I  have  seen  a  number  of  patients  who,  a 
short  time  prior  to  death,  became  extremely  confused  and  thought 
themselves  two  different  individuals.  In  one  instance  the  pa- 
tient kept  expectorating  carelessly  about  on  the  bed  clothing 
and  floor,  and,  when  reproved  for  it,  said  that  he  was  two  indi- 
viduals and  that  the  other  fellow  did  the  expectorating  and  used 
the  cup.  Such  patients  sometimes  think  that  one  personality 
is  a  long  way  off  and  the  other  one  present.  I  have  noticed  this 
as  a  terminal  symptom,  coming  on  during  the  last  few  weeks 


PSYCHONEUROSES  151 

of  life,  except  in  one  instance  under  my  care  at  the  present  time. 
This  patient,  a  young  woman,  began  to  suffer  from  active  symp- 
toms accompanied  by  fever  about  four  months  ago.  One  month 
later  she  was  having  chills  with  high  fever,  and  suffered  greatly 
from  the  cold.  In  describing  her  conceptions,  she  says  that  she 
herself  was  always  comfortable,  but  that  she  could  not  keep  the 
other  personality  warm  no  matter  how  much  cover  she  used.  She 
also  thought  of  the  other  person  as  doing  all  of  the  coughing  and 
expectorating,  while  she  did  none.  This  patient  is  suffering  from 
advanced  caseous  tuberculosis  with  fever  and  a  complicating  tu- 
berculous enteritis.  (She  died  two  months  after  this  was  writ- 
ten, six  months  after  first  noting  the  double  personality.) 

Psychoneuroses. — More  frequent  than  the  psychoses  are  the 
psychoneuroses  and  neuroses.  Tuberculosis  often  develops  in  in- 
dividuals of  the  nervous  type.  Sometimes  this  nervous  condi- 
tion is  inherited.  In  those  of  the  enteroptotic  type  (astJienica 
universalis  congenita),  Stiller  claims  that  the  nervous  character- 
istics are  present  from  birth  but  become  manifest  more  particu- 
larly after  puberty.  In  other  instances  the  nervous  symptoms 
gradually  appear  as  a  result  of  toxins  which  develop  in  the  focus 
of  infection. 

In  many  children  tubercle  toxins  injure  the  nervous  system, 
destroying  the  nerve  balance ;  and,  through  this,  interfere  with 
proper  physical  development.  This  harmful  influence  on  the 
nervous  system  is  often  carried  on  for  a  prolonged  period  be- 
fore frank  clinical  tuberculosis  develops.  It  is  often  difficult, 
under  such  circumstances,  to  tell  whether  the  nervous  condition 
or  the  tuberculosis  existed  first. 

The  nervous  side  of  tuberculosis  has  impressed  some  authors 
so  thoroughly  that  they  look  upon  it  as  being  a  nervous  dis- 
ease. One  can  readily  understand  how  the  toxemia  of  tubercu- 
losis can  produce  a  vicious  circle  by  its  action  upon  the  nervous 
system  and,  through  it,  interfere  with  the  physical  development. 
Realising  that  one  of  the  important  functions  of  the  nervous 
system  is  to  preside  over  the  nutrition  of  the  body  cells,  the 
effect  of  a  more  or  less  constant  toxemia,  such  as  that  produced 
by  chronic  tuberculosis,  is  evident.  By  its  action  on  the  neurons 
there  is  a  constant  disturbance  in  nerve  impulses  which  must  be 
conducted  to  the  tissue  cells  through  the  nerve  filaments.    It  is 


152  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

quite  possible  that  this  is  the  true  cause  of  the  degenerations 
which  result  from  toxemia. 

"While,  as  yet,  we  are  not  wholly  able  to  explain  the  action  of 
toxemia,  yet  we  are  able  to  say  that  its  force  seems  to  be  spent 
directly  upon  the  central  nerve  cells,  the  effect  of  which  is  shown 
in  disturbed  function.  "While  our  knowledge  of  the  physiology 
of  the  nervous  system  would  not  permit  us  to  believe  that  the 
sympathetic  neurons  alone  are  involved,  yet  the  syndrome  of 
toxemia  is  that  of  a  general  discharge  through  the  sympathetic 
nervous  system.  "We  must  conceive  that  the  chronic  toxemia 
produces  more  or  less  constant  stimulation  of  the  nerve  cells  of 
the  central  nervous  system.  Eesulting  from  this  they  become 
more  or  less  irritable,  fatigued  and  later,  exhausted.  This  ir- 
ritability is  shown  in  dysfunction  on  the  part  of  the  organ  re- 
ceiving its  nerve  impulse  from  the  cells  which  are  involved.  One 
particular  action  caused  by  toxins  is  its  stimulation  through  the 
sympathetics  of  the  adrenal  gland  with  an  increased  produc- 
tion of  adrenin.  This,  again,  stimulates  the  sympathetic  nerves 
peripherally  and  prolongs  the  action  produced  by  toxemia.  "While 
the  toxins  act  upon  the  central  nerve  cells,  adrenin  acts  peripher- 
ally at  the  myo-neural  junction.  "With  stimulation  of  the  sym- 
pathetics, either  centrally  or  peripherally,  we  have  a  general  in- 
hibition of  function  throughout  the  important  internal  viscera 
which  produces  an  extremely  deleterious  effect  upon  the  organ- 
ism as  a  whole. 

The  irritability  of  the  nerve  cells  shows  itself  by  a  lowering 
of  the  threshhold  of  response,  so  that  a  stimulation  which,  under 
ordinary  circumstances,  would  be  withstood  by  the  nerve  cell 
without  resultant  action,  calls  forth  an  action  more  or  less  in- 
tense. 

From  this  description  it  can  be  readily  seen  that  the  psycho- 
neuroses  of  the. tuberculous  are  characterized  by  lack  of  endur- 
ance and  increased  irritability. 

Nearly  every  adult  who  suffers  from  clinical  tuberculosis  has 
a  more  or  less  pronounced  neurasthenia,  which  becomes  more 
marked  as  toxemia  is  prolonged.  These  patients  suffer  from 
malaise.  They  are  weary  even  without  exertion  and  tire  unduly 
upon  the  least  effort,  whether  of  a  physical  or  mental  nature. 
Added  to  this  is  often  a  complete  change  in  nature,  an  irritabil- 


MENTAL    ATTITUDE  153 

ity,  a  lack  of  self-control.  A  quiet  nature  may  become  easily 
angered  and  even  quarrelsome.  Dependence  is  also  a  common 
symptom.  Patients  who  have  been  self-reliant  often  lose  their 
confidence  in  themselves.  They  like  to  have  things  done  for 
them,  and  even  see  their  friends  make  unusual  sacrifices  with- 
out show  of  appreciation. 

The  nature  of  the  tuberculous  often  becomes  much  like  that 
of  the  child, — selfish,  self-centered,  irritable,  easily  angered  and 
easily  pleased. 

McCarthy  and  Carncross1  present  a  careful  study  of  the 
mental  attitude  of  the  tuberculous  patients  treated  under  their 
care  during  the  years  1904-5.  The  mental  attitude  of  these  pa- 
tients might  be  somewhat  different  from  that  of  the  patients  in 
the  well-to-do  class,  but  the  analysis  is  very  interesting.  Carn- 
cross says: 

"The  question,  then,  must  be  not  are  tuberculous  people  par- 
ticularly optimistic  or  hopeful  or  cheerful  or  anything  else,  but 
do  they  undergo  a  change  of  mental  state?  And  this  I  think 
may  be  answered  reservedly  in  the  affirmative — so  reservedly, 
indeed,  that  one  must  say  that  generally  the  change  is  due  to 
chronic  illness  rather  than  to  tuberculosis  specifically.  Having 
claimed  this  freedom  from  specific  influence,  one  must  promptly 
whirl  about  and  assert  that  in  a  certain  number  of  cases  the  dis- 
ease does  not  affect  the  brain  markedly, — that  here  are  found 
more  or  less  characteristic  mental  states  which  are  over  the 
borderland.    But  of  these  I  shall  speak  later  on. 

"Well,  then,  in  the  long  run,  what  are  the  changes,  if  there 
are  any,  in  disposition  or  mental  state  that  the  tuberculous  in- 
dividual does  undergo1?  They  are  what  one  would  expect  from 
the  condition  of  the  general  nervous  system,  which  is  one  of 
irritability — the  irritability  of  weakness.  The  spinal  reflexes  are 
almost  universally  increased  before  the  very  advanced  stages 
have  been  reached,  in  a  limited  number  of  which,  as  Doctor  Mc- 
Carthy has  shown,  they  are  abolished.  And  this  same  irritability 
is  evident  in  the  brain.  The  vast  majority  of  tuberculous  pa- 
tients will  promptly  admit  that  they  are  irritable  since  they  have 
been  afflicted  with  the  disease.     They  frequently  describe  them- 


1Second  Annual  Report  of  the  Henry  Phipps  Institute  for  the  Study,  Treatment,  and 
Prevention  of  Tuberculosis,  Philadelphia,   1906. 


154 


NERVOUS  SYSTEM  IN  TUBERCULOSIS 


selves  as  'cranky.'  "With  this,  in  many  eases,  is  a  greater  ten- 
dency to  worry,  though  here,  of  course,  circumstances,  which 
have  become  so  much  more  unfavorable,  play  a  large  part.  But 
the  sense  of  apprehension  and  the  dread  of  trouble,  as  well  as 
the  susceptibility  to  annoyance,  are  increased  independently  of 
external  conditions.  The  patient  often  admits  that  he  is  less 
cheerful  and  less  sociable,  and  that  his  outlook  tends  more  to- 
ward pessimism.  On  the  other  hand,  he  may  simply  be  more 
indifferent,  or  quieter,  or  have  become  entirely  ambitionless. 
Any  one,  two,  or  all  of  these  changes  may  be  present  in  the 
tuberculous  individual." 

The  following  tables  which  are  self-explanatory,  show  the  nat- 
ural disposition  of  the  patient  and  the  attitude  after  tuberculosis 
has  developed  (McCarthy  and  Carncross).  They  do  not  bear  out 
the  universality  of  the  condition  of  spes  plitliisica  which  seems  to 
be  so  generally  accepted. 

Disposition. 


Patients 
with 


Cheerful    temperament.  155' 
Unhappy  temperament.   22 
Intermediate     tempera- 
ment      29 

No   record  of  tempera- 
ment      31 


Some  change   in   dispo- 
sition     148 

(18    non-tuberculous) 
No    change   in    disposi- 
tion        58 

(5  non-tuberculous) 
No  record  of  change  in 

disposition     31 

(7  non-tuberculous) 


237 


Present  Mental  Attitude. 


{Hopeless  regarding  disease 166 
Not  hopeful  regarding  disease . .  32 
Indifferent  regarding  disease. ...  1 
No  record 38 


Patients 
who  were 


rMost  of  the  time.  62 
Depressed. . .  J  At  times  49 

[Seldom 14 

Not  depressed    71 

No  record   41 


Patients       f  Suspicious     10 

who  were     \  Not  suspicious   184 

I  No  record   43 


16  non-tuberculous)  1 
4  non- tuberculous)  I     007 

10  non-tuberculous)  J 


6  non-tuberculous) 

10  non-tuberculous) 

1  non-tuberculous) 

6  non-tuberculous) 

7  non-tuberculous) 


}    237 


2  non-tuberculous)  "1 

20  non-tuberculous)  > 

8  non-tuberculous)  J 


237 


Five  of  the  one  hundred  and  eighty-four  recorded  as  not  suspicious  were  ques- 
tionable. 


TUBERCULOSIS    AND    MENTAL    ATTITUDE  155 

The  tuberculous  patient  is  generally  looked  upon  as  being  one 
of  unusual  hope.  I  have  never  been  able  to  make  up  my  mind 
that  he  is  far  different  in  this  respect  from  what  he  was  before 
his  illness.  One  optimistic  when  well,  is  apt  to  be  when  ill  of 
tuberculosis,  and  there  is  surely  nothing  in  this  disease  that  can 
turn  a  pessimist  into  an  optimist.  If  we  consider  the  seriousness 
of  the  disease  we  must  marvel  at  the  hopefulness  of  those  who 
are  inclined  to  be  of  a  hopeful  nature;  on  the  other  hand  the 
confirmed  pessimist  is,  at  least,  as  hard  to  cheer  and  encourage 
when  tuberculous  as  when  well. 

There  is  one  factor  which  acts  by  inspiring  hope  all  along 
through  the  course  of  the  disease.  That  is  that  they  have  spells 
of  illness,  the  disease  becoming  more  active  than  usual  and  be- 
ing accompanied  by  temperature,  chills,  and  other  symptoms  of 
toxemia,  increased  cough  and  expectoration,  to  be  followed  again 
by  a  remission  or  cessation  after  a  short  time.  They  see  this  so 
often  that  they  expect  it,  and  consequently  learn  to  look  for- 
ward to  the  time  when  they  will  be  better,  no  matter  how  ill 
they  are.  While  this  is  the  attitude  of  the  optimist,  the  pessimist 
often  greets  his  physician,  who  is  trying  to  encourage  him,  by 
such  statements  as:  "Yes,  but  how  long  will  it  last?"  or  "Yes, 
but  I  have  been  this  way  before  and  it  always  gets  worse. ' '  Com- 
pared with  the  patient  with  severe  acute  illnesses,  in  which  tox- 
emia is  a  factor,  or  chronic  diseases  accompanied  by  toxemia, 
I  think  the  tuberculous  patient  is  in  about  the  same  frame  of 
mind  during  his  periods  of  acute  activity,  and  during  lesser  ac- 
tivity, as  one  with  other  chronic  toxemia ;  but,  of  course  he  is  hope- 
ful and  buoyant,  if  an  optimist,  when  the  toxic  symptoms  have 
passed  off.  If  a  pessimist  he  is  always  pessimistic.  I  have  never 
been  able  to  determine  that  the  tuberculous  patient,  with  severe 
gastrointestinal  complications  is  any  less  depressed  than  the  non- 
tuberculous  with  the  same  symptoms. 

The  tuberculous  patient  is  often  described  as  one  who  is  par- 
ticularly credulous  and  easily  duped.  In  this  way  do  some  ac- 
count for  the  fact  that  he  is  preyed  upon  to  such  an  extent  by 
quacks,  charlatans,  and  the  unscrupulous.  Is  he  more  easily 
duped  than  the  average  human  being?  Before  answering  this 
we  must  recognize  that  he  is  suffering  from  a  serious  fatal  dis- 
ease. Our  profession  has  offered  him  little  hope,  in  fact,  has 
told  him  time  after  time,  that  it  can  do  nothing  for  him.    Nat- 


156  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

urally,  he  exercises  his  right,  if  not  his  judgment,  and  turns  to 
the  thing  that  does  offer  hope.  It  is  doubtful  whether  this  is 
an  indication  of  excessive  gullibility.  Is  it  not  just  as  apt  to  be 
a  bowing  to  the  principle  of  self-preservation,  the  first  law  of 
nature?  Are  they  more  gullible  than  others  who  follow  fake 
advertisements  not  only  in  medicine  but  in  every-day  transac- 
tions? Are  they  more  easily  duped  than  other  intelligent  people 
who  blindly  follow  cults  and  fakers'? 

The  fact  has  been  cited  that  they  are  so  easily  preyed  upon 
that  any  new  measure  for  relief  is  accepted  with  unusual  eager- 
ness and  that  every  suggestion  of  itself  is  apt  to  be  noted.  This 
may  be  explained  on  the  ground  that  relieving  fear  and  discour- 
agement and  substituting  hope  in  their  place  relieves  the  patient 
of  sympathetic  inhibition  and  improves  his  general  tone,  as  noted 
on  page  224.  This  is  not  peculiar  to  the  tuberculous.  The  non- 
tuberculous  can  also  be  put  to  sleep  at  times  by  a  hypodermic 
of  sterile  water;  so  can  they  be  relieved  of  pain  by  the  same. 

The  human  race,  as  a  whole,  is  influenced  by  suggestion,  and 
to  this  the  tuberculous  patient  is  not  an  exception.  One  of  the 
greatest  factors  in  handling  the  tuberculous  patient  is  sugges- 
tion. This  factor  is  most  important  in  its  influence  on  the  ner- 
vous system.  The  nervous  system  controls  every  function  of 
the  body,  so  its  effect  is  far  reaching.  Positive  suggestion  is  a 
powerful  force  and  should  always  be  employed.  It  should  be  so 
positive  too  that  it  will  overcome  all  negative  suggestions  that 
can  come  from  outside  sources.  It  is  difficult  to  measure  the 
influence  of  suggestion  upon  the  cure  of  tuberculosis,  but  it  can- 
not be  denied  that  proper  suggestion  will  relieve  sympathetic 
inhibition,  produce  a  calm  state  of  mind,  induce  sleep,  improve 
digestion  and  assimilation,  and  have  a  favorable  influence  upon 
the  heart  and  circulatory  system ;  but,  this  it  will  do  for  the  non- 
tuberculous  as  well  as  tuberculous. 

There  are  many  circumstances,  when  numbers  of  tuberculous 
patients  are  under  close  observation,  that  make  it  appear  that 
they  lack  will  power  and  are  extremely  easily  led.  In  my  ex- 
perience I  would  say  that  three-fourths  of  the  patients  who  have 
confidence  enough  to  seek  my  aid  are  willing  to  cooperate  to 
the  best  of  their  ability,  while  the  others  need  considerable  at- 
tention to  hold  them  to  conscientious  work.     In  discussing  this 


TUBERCULOSIS    AND    MENTAL    ATTITUDE  157 

in  a  former  paper2  the  writer  said:  "The  patients  who  enter  an 
institution  belong  to  three  classes.  The  first  comprises  the  great 
majority  of  patients  and  consists  of  those  who  want  to  do  what 
is  right,  who  are  conscientious  and  earnest  in  their  desire  to  get 
well.  To  be  sure  these,  at  times,  fall  from  grace;  but,  most  of 
the  time  they  are  working  conscientiously  for  recovery.  Then, 
there  is  a  small  class,  probably  about  twenty  per  cent,  who  have 
no  well  defined  principles,  but  who  are  willing  to  be  conscientious 
if  they  fall  in  with  the  conscientious  class,  and  who  are  just  as 
willing  to  be  insincere  if  they  are  led  that  way.  Then  there  is 
still  a  small  number,  less  than  five  per  cent,  who  are  vicious, 
willful  and  unfaithful  to  themselves  and  all  with  whom  they 
come  in  contact.  This  class,  however,  can  often  be  controlled 
by  patience  and  firmness." 

I  am  not  sure  that  a  lack  of  cooperation  on  the  part  of  the 
few  can  be  attributed  to  lack  of  will  power.  It  is  rather  thought- 
lessness combined  with  the  usual  disregard  of  other  people's 
rights  and  an  unwillingness  on  their  part  to  submit  to  authority. 
It  may  be  exaggerated  over  what  it  would  be  among  an  equal 
number  of  well  people,  yet  of  this,  I  am  not  sure. 

Von  Muralt3  speaks  of  the  suspiciousness  of  the  tuberculous 
patients  and  notes  how  they  mistrust  particularly  those  who  are 
trying  to  do  for  them.  He  also  speaks  of  their  egoistical  na- 
ture, their  lack  of  regard  for  others.  He  speaks  of  how  at  times 
they  will  suddenly  become  dissatisfied  with  everything  that  is 
being  done  for  them;  and  says  that  every  sanatorium  physician 
has  met  epidemics  of  complaints  against  the  administration  and 
dissatisfaction  with  the  methods  of  treatment  which  were  not 
only  unfounded  but  amounted  to  base  ingratitude.  Such  attacks 
as  these  are  accounted  for  on  the  ground  of  toxic  disturbances 
of  the  nervous  system.  There  is  no  doubt  of  the  effect  of  the 
toxins  upon  the  nervous  system,  yet  such  behavior  has  nothing 
to  do  with  tuberculosis  itself.  True,  it  may  be  somewhat  ac- 
centuated by  it;  but  would  not  these  same  tendencies  show  them- 
selves in  any  group  of  individuals  who  were  under  similar  dis- 


2Some  of  the  Problems  of  Private  Sanatoria  for  Tuberculosis  as  Observed  During 
Ten  Years'  Experience  in  the  Pottenger  Sanatorium  for  Diseases  of  the  Lungs  and 
Throat,  Boston  Medical  and  Surgical  Journal,  vol.  clxxi,  no.  4,  pp.  142-147,  July  23,  1914. 

8Die  nervosen  und  psychischen  Stoerungen  der  Lungentuberkulosen,  Medizinische 
Klinik,  1913,  N.  44  and  46.  .      i    ■ 


158  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

appointment  and  discouragement,  and  under  the  same  restraint; 
and  would  not  they  manifest  themselves  in  any  group  of  indi- 
viduals suffering  from  chronic  toxemia  from  any  other  cause? 

Insomnia  is  often  a  symptom  which  seems  to  be  exaggerated 
in  tuberculosis.  This  is  very  apt  to  occur  in  people  who  are  of 
a  nervous  temperament.  An  obstinate  insomnia  which  fails  to 
yield  to  ordinary  and  even  extraordinary  doses  of  hypnotics,  is 
a  very  common  symptom  which  comes  on  a  few  weeks  before 
and  persists  until  death. 

Hezel4  quotes  the  following  statistics  of  marked  instances  of 
psychoneuroses  in  tuberculosis.  He  himself  found  it  in  30  to  40 
per  cent,  Phillipi  in  66.1  per  cent  of  all  patients  of  which  there 
were  52  per  cent  in  the  first  stage;  59  per  cent  in  the  second,  and 
76.6  in  the  third  stage. 

The  ultimate  dependence  of  these  neurotic  symptoms  upon 
toxemia  may  be  inferred,  however,  from  the  fact  that  they  are 
often  markedly  increased  during  acute  activity  and  disappear 
with  its  quiescence.  During  the  time  that  necrosis  and  cavity 
formation  are  occurring  we,  at  times,  find  these  symptoms  very 
pronounced  and  see  them  let  up  simultaneously  with  the  rupture 
and  expulsion  of  the  contents.  These  symptoms,  although  very 
pronounced  when  the  patient  is  living  under  unhygienic  condi- 
tions, are,  at  times,  relieved  at  once  when  the  patient  is  put  at 
rest  under  a  hygienic  regime.  The  fact,  however,  that  many 
of  them  can  be  markedly  relieved  by  suggestion,  indicates  that 
toxemia  is  not  the  only  factor.  The  effect  of  depressive  emo- 
tional states  such  as  pain,  discouragement,  fear  and  disappoint- 
ment must  be  taken  into  consideration  in  this  connection.  For 
a  more  complete  discussion  of  this  interesting  phase  of  the  sub- 
ject see  Chapter  VIII.  There  seems  to  be  considerable  habit  in 
all  cases  of  psychoneuroses;  although,  to  begin  with,  there  is 
some  physical  foundation  in  practically  all  instances. 

The  relationship  between  neurasthenia  and  tuberculosis  is 
gradually  becoming  better  recognized.  The  toxins  of  tubercu- 
losis are  especially  prone  to  affect  the  nervous  system.  Now  that 
we  begin  to  appreciate  the  fact  that  tubercle  bacilli  taken  into 
the  body  during  childhood  may  not  produce  active  tuberculosis 


4Tuberkulose   und   Nerven   System,  Handbuch   der   Tuberkulose,    Brauer,    Schroder  und 
Blumenfeld,   Bd.   iv,   1914. 


TUBERCULOSIS    AND    NEURASTHENIA  159 

until  later  in  life,  we  begin  to  understand  how  these  infections 
may  be  able  intermittently  to  give  off  enough  toxins  to  impair 
seriously  the  nervous  system,  without  producing  more  active 
symptoms.  Every  observing  clinician  can  probably  recall  cases 
of  so-called  neurasthenia  which  have,  upon  careful  analysis, 
proved  to  have  a  partially  quiescent  tuberculosis  as  their  causa- 
tive factor.  This  can  be  understood  by  realizing  that  the  toxins 
constantly  bombard  the  cells  of  the  central  nervous  system  and 
irritate  them  to  the  point  of  exhaustion. 

It  is  extremely  important  to  bear  this  in  mind,  particularly 
in  young  girls  and  boys  during  the  age  of  adolescence.  In  nor- 
mal individuals  this  should  be  the  period  of  exceptional  devel- 
opment and  increased  strength  and  power.  We  find  quite  a 
proportion  of  young  people,  who,  instead  of  taking  upon  them- 
selves this  extra  growth,  seem  to  be  unable  to  measure  up,  and 
seem  to  gradually  lose  in  strength  and  power  instead.  This  is 
the  time  those  suffering  from  astJienica  universalis  congenita 
(Stiller)  begin  to  show  this  stigma  most.  It  is  the  time  when 
the  so-called  neurasthenic  condition  begins.  While  there  are  un- 
doubtedly many  individuals  whose  lack  of  nervous  and  physical 
force  is  a  congenital  factor,  yet  there  are  many  others  who  de- 
velop this  after  birth,  showing  it  particularly  after  the  age  of 
puberty. 

I  wish  to  emphasize  that  the  tubercle  toxins  which  are  given 
off  from  the  semi-quiescent  foci  which  are  often  present  in  early 
life  and  adolescence  are  responsible  for  many  cases  of  neuras- 
thenia. This  is  true  to  such  an  extent  that  tuberculosis  should 
always  be  considered  as  one  of  the  etiological  factors  in  neu- 
rasthenia coming  on  at  this  time  of  life. 

I  have  seen  many  young  people,  particularly  girls,  who  were 
gradually  lapsing  into  this  neurasthenic  state,  who  have  been 
relieved  and  practically  made  over  by  discovering  that  the  tuber- 
culous toxemia  was  the  underlying  cause  and  relieving  it  by 
proper  treatment. 

Pathology  of  Psychoses  and  Psychoneuroses. — Dupre,5  quoted 
by  Hezel,  speaks  of  the  pathology  of  the  psychoneuroses  and 
psychoses  in  tuberculosis.  He  mentions  a  patient  who  came 
to  postmortem  who,  during  the  last  few  months  of  life,  had  suf> 


BEuphorie   d&irante   des   phthisiques,    Etude   anatomaclinique    Revue   neurol,    1904,    No. 
16,    Ref.    Neurologisches,   Centralblatt,    1904,   p.    1164. 


160  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

fered  from  light  characteristic  attacks  of  depressive  mania.  He 
found  over  the  frontal  lobe  slight  thickness  of  the  meninges  with- 
out adhesions,  also  a  slight  hydrocephalus,  but  no  signs  of  tu- 
berculous infection.  Histological  examination  using  Nissl  stain 
showed  a  simple  meningitis,  not  inflammatory  in  character;  and 
without  diapedesis.  In  the  brain  there  was  a  slight  proliferation 
of  the  epithelium  of  the  vessels,  pigmentation  around  the  vessels, 
and,  in  the  tissues  surrounding  the  capillaries,  an  occasional 
columnar  cell.  Scarcely  any  increase  of  the  glia  cells  was  ob- 
servable. In  the  ganglion  cells  of  the  frontal  lobe  there  were 
marked  degenerative  changes,  also  destruction  of  the  white  sub- 
stance. Chains  of  strepto-bacilli  were  seen  around  some  of  the 
vessels.  In  the  other  portions  of  the  cortex  these  processes  were 
much  less  marked.  Dupre  considers  them  as  purely  toxic,  neither 
of  a  meningeal  nor  bacillary  nature. 

Levastine,6  quoted  by  Hezel,  reports  that  he  has  found  cell 
degeneration  in  the  cortex  of  tuberculous  patients  who  had 
shown  evident  psychoneurotic  disturbances  during  life;  and  has 
noted  marked  pigmentation  of  the  cortical  cells  in  cachectic  pa- 
tients. These  reports  are  very  interesting  because  they  show 
the  extent  of  the  toxic  influence  of  this  disease. 

Tuberculosis  and  the  Peripheral  Nerves. — The  influence  of  tu- 
berculosis upon  the  peripheral  nerves  has  received  some  study 
during  recent  years,  although  for  the  most  part  it  has  been 
neglected.  A  nerve  may  either  be  influenced  directly  by  the 
tuberculous  process  in  adjacent  tissue  such  as  occurs  when  the 
vagus  nerve  is  bound  down  by  enlarged  mediastinal  glands,  or 
the  phrenics  are  involved  in  apical  adhesions  or  the  intercostals 
are  involved  in  instances  of  pleural  adhesions;  or,  as  pointed 
out  by  Gustav  Liebermeister7  the  nerves  themselves  may  be  in- 
fluenced through  the  direct  action  of  bacilli.  The  toxic  influence 
has  been  previously  mentioned  and  is  undoubtedly  of  consider- 
able importance.  Reflex  action  upon  the  peripheral  nerves  has 
particularly  interested  the  writer  for  a  number  of  years.  The 
disturbance   in   the   larynx   in    early   tuberculosis    is    sometimes 


6Reclierches  histologiques  sur  l'ecorce  cerebrale  des  tuberculeux  Revue  de  Med.,  No. 
3,    1907,    Ref.    Jahresbericht    d.    Neurol,    u.    Psychiatr. 

'Studien  iiber  Komplikationen  der  Ivungentuberkulose  und  iiber  die  Verbreitung  der 
Tuberkelbacillen  in  den  Organen  und  im  Blut  der  Phthisiken,  Virchow's  Archiv  fur 
pathologische  Anatomie  und  Physiologic  und  fur  Klinische  Medicin,  vol.  xix  (series  19, 
vol.   vii),   part    1-2-3. 


EFFECT    ON    PERIPHERAL    NERVES  161 

thought  to  be  due  to  the  recurrent  laryngeal  being  compressed 
by  enlarged  mediastinal  glands.  I  think,  however,  that  this  is 
more  apt  to  be  a  reflex  hoarseness  which  appears  in  tuberculosis 
and  presents  two  different  pictures  upon  physical  examination. 
In  one  instance  there  is  an  inability  to  adduct.  This  is  due  to 
interference  with  the  action  of  the  recurrent  laryngeal.  In 
other  instances  the  cords  approximate  at  the  ends  but  lack  tone 
and  consequently  do  not  approximate  in  the  middle.  This  is 
due  possibly  to  interference  with  the  action  of  the  superior  laryn- 
geal. I  am  inclined  to  think  that  these  processes  are  due  to  a 
reflex  stimulation  from  the  disease  in  the  lung,  the  irritation 
starting  in  the  inflammation  in  the  lung,  the  afferent  impulse 
traveling  to  the  brain  and  coming  back  through  the  superior  and 
inferior  laryngeal  nerves.  I  have  gone  into  the  question  of  re- 
flexes more  fully  elsewhere  and  would  refer  my  reader  to 
page  385. 

In  1912  the  writer  reported  several  cases  of  acute  neuritis  re- 
gional in  character  which  resulted  from  tuberculosis.8  Two  of 
these  involved  the  brachial  plexus.  Since  that  time  I  have  had 
seven  others  under  my  care,  making  nine  cases  of  brachial  neu- 
ritis in  all,  which  were  confined  to  the  side  of  severest  involvement 
and  greatest  activity  in  patients  suffering  from  pulmonary  tuber- 
culosis. The  fact  that  they  were  confined  to  the  side  of  the  in- 
volvement; or,  where  both  sides  were  involved,  to  the  side  of 
greatest  activity,  warrants  the  belief  that  they  were  directly  re- 
lated to  the  disease.  In  my  papers  dealing  with  muscle  spasm 
as  a  motor  reflex9  I  called  attention  to  the  fact  that  these  nerve 
lesions  are  not  a  part  of  the  general  nerve  disturbance  which 
might  be  due  to  toxemia,  but  have  a  definite  regional  character. 
The  fact  that  this  regional  relationship  can  be  traced  anatomic- 
ally to  an  association  between  the  cervical  nerves  and  the  sym- 
pathetic nerves  which  supply  the  lung  leads  us  to  the  con- 
clusion that  they  are  reflex  in  nature.  Patients  having  tubercu- 
losis suffer  from  sensory,  motor,  trophic  and  secretory  disturb- 
ances of  reflex  character  and  in  some   of  these  instances  the 


8Chest  and  Shoulder  Pains  in  Pulmonary  Tuberculosis,  Transactions  of  the  American 
Climatological   Association,    1912. 

8Muskelspasmus  und  Degeneration,  ihre  Bedeutung  fur  die  Diagnose  intrathorazischer 
Entziindung  und  als  Kausalfaktor  bei  der  Produktion  von  Veranderungen  des  knoch- 
ernen  Thorax  und  leichte  Tastpalpation,  Brauer's  Beitrage  zur  Tuberkulose,  Bd.  xxii, 
part  1,  1912;  Muscle  Spasm  and  Degeneration  in  Intrathoracic  Inflammation  and  Eight 
Touch  Palpation,   C.  V.  Mosby  Co.,  St.   Louis,   1912. 


162  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

nerves  themselves  show  a  distinct  pathology.  Clinically,  where 
the  nerve  is  inflamed,  it  is  accompanied  by  certain  phenomena. 
Pain  is  a  common  accompaniment,  although  it  may  be  so  slight 
in  character  that  it  is  only  an  uneasiness  or  a  feeling  of  being 
tired.  These  sensations  are  expressly  noticed  through  the  shoul- 
ders and  interscapular  region  and  are  nearly  always  confined 
to  the  side  where  the  lung  is  involved.  A  pain  of  this  character 
which  I  have  not  previously  seen  described  is  one  which  affects 
the  pharynx.  This,  when  present,  nearly  always  comes  on  when 
the  disease  is  far  advanced.  The  patient  complains  of  pain  in 
the  throat  and  yet  nothing  can  be  seen.  These  pains  are  entirely 
different  from  the  sensory  disturbances  which  have  been  de- 
scribed by  Head.  Head  has  shown  segmental  relationship  be- 
tween the  reflexes  of  the  lung  and  the  skin,  and  in  this  has  laid 
the  foundation  for  the  theory  underlying  the  writer's  observa- 
tions. Every  internal  organ  has  a  corresponding  area  on  the 
surface  of  the  body  in  which  hyperalgesia  may  be  reflexly  de- 
veloped when  the  organ  is  inflamed.  This  area  is  the  one  sup- 
plied by  sensory  nerves  from  the  segments  of  the  cord  which  are  in 
communication  with  the  affected  organ  through  the  sympathetics 
which  supply  it.  The  segments  of  the  cord  which  stand  in  particu- 
lar relationship  to  the  lungs  are  the  third  and  fourth  cervical  and 
third  to  ninth  dorsal,  particularly  the  fourth  and  fifth  dorsal. 
The  lungs  are  connected  by  few  communicating  branches  with 
the  fifth  to  eighth  cervical  nerves. 

Not  only  do  we  have  sensory,  but  also  motor  reflexes  as  I 
have  shown.  The  motor  nerves  in  reflex  communication  with 
the  lung  show  true  degenerative  inflammation.  In  this  way  I 
account  for  the  instances  of  neuritis  which  I  mention.  Justi- 
fication of  the  theory  that  these  pains  are  due  to  inflammation 
of  the  nerve  from  reflex  sources,  is  found  in  the  clinical  fact 
that  the  muscles  supplied  by  the  nerves  from  the  segments  in 
question  take  upon  themselves  increased  tone  or  spasm  when  the 
pulmonary  involvement  is  active,  and  degeneration  when  it  quiets 
down,  which  indicates  a  serious  nerve  disturbance.  In  a  former 
discussion  the  writer  said:10 

"While  I  do  not  wish  to  enter  into  a  full  discussion  of  the 


10Muscle   Spasm   and  Degeneration   in  Intrathoracic   Inflammation  and  Eight   Touch   Pal- 
pation, C.  V.  Mosby  Company,   St.  Eouis,   1912. 


TUBERCULOSIS    AND    PERIPHERAL    NEURITIS  163 

many  pains  that  accompany  intrathoracic  inflammations  (espe- 
cially when  found  in  tuberculosis)  yet  I  cannot  refrain  from 
suggesting  that  their  character  indicates  that  some  of  them  are 
phenomena  of  reflex  origin.  I  am  well  aware  that  the  theory 
of  a  reflex  will  not  explain  all,  for  we  must  recognize  pleurisy, 
pressure  pains,  and  general  pains  which  are  found  in  all  parts 
of  the  body  which  may  be  of  toxic  origin.  But,  aside  from  these, 
we  have  regional  or  localized  pains,  the  same  as  we  have  local- 
ized muscular  contractions  and  atrophies,  which  must  be  ex- 
plained by  some  locally  acting  cause.  As  a  hint  to  explanation 
we  find  these  localized  pains  for  the  most  part,  as  far  as  I  have 
been  able  to  determine,  on  the  same  side  on  which  the  involve- 
ment exists.  Thus  it  seems  natural  to  suggest  for  them  a  com- 
mon cause  with  other  reflex  phenomena. 

"Of  such  regional  pains  the  vague  sensations  which  are  found 
in  the  shoulder  or  shoulders  in  case  of  infection  of  both  lungs 
must  be  mentioned.  These  often  begin  as  early  as  clinical  symp- 
toms appear.  They  vary  in  intensity  from  a  mere  'feeling  of 
being  tired'  to  an  aching  more  or  less  severe.  Aside  from  these 
vague  feelings  of  discomfort  we  find  pains  of  a  very  severe  char- 
acter which  leave  no  doubt  as  to  their  nature.  They  are  a  true 
neuritis.  These  we  find  especially  about  the  neck,  shoulder  (oc- 
casionally running  into  the  arm),  and  upper  portion  of  the  chest 
both  anteriorly  and  posteriorly.  I  have  seen  some  instances  in 
which  the  pain  in  these  cases  was  so  severe  that  it  was  neces- 
sary to  resort  to  morphine  injections.  In  some  cases  which  I 
have  observed  there  was  a  marked  wasting  with  loss  of  muscular 
power.  One  thing  characteristic  of  all  these  pains  is  that  they 
are  not  constant.  They  come  and  go  and  are  influenced  by 
weather  conditions  and  barometric  changes. 

"These  cases  have  been  misunderstood,  wrongly  diagnosed  and 
consequently  wrongly  treated.  They  are  quite  often  treated  for 
rheumatism. 

"The  following  cases  will  illustrate  the  severe  forms: 

"Mrs.  B.  Age  32,  had  suffered  from  a  slight  infection  of  the  right  apex 
and  an  advanced  tuberculous  process  of  the  upper  left  lung  which  had 
ended  in  cavity  formation  and  healing.  She  had  also  had  tuberculous  ul- 
ceration in  the  interarytenoid  space  and  left  cord  which  resulted  in  heal- 
ing. She  suffered  a  great  deal  from  aching  of  the  left  shoulder  during 
her  illness,   and   during  the   latter  part   of  her   treatment  suffered   severe 


164  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

pain  running  up  the  left  side  of  the  neck,  which  persisted,  at  intervals, 
for  months,  and  then  finally  disappeared. 

"Mr.  L.  consulted  me  in  February,  1911,  for  a  widespread  ulcerative 
condition  of  the  larynx.  Upon  examination  of  the  chest  I  found  an  old 
fibroid  lesion  of  the  right  lung  occupying  the  upper  half  of  the  upper  lobe, 
which  was  the  seat  of  renewed  activity.  I  told  him  my  findings,  that  he 
had  evidence  of  an  old  lesion  in  the  lung.  He  protested  that  it  could 
not  be.  I  inquired  as  to  his  reason  for  leaving  Philadelphia,  which  was 
his  former  home.  He  said  he  left  because  he  had  suffered  from  a  severe 
rheumatism  of  the  right  shoulder  which  partially  incapacitated  him  for 
business.  I  asked  him  if  he  was  examined.  He  said  he  had  consulted 
nearly  a  dozen  of  the  best  men  there,  all  of  whom  had  pronounced  the 
ease  rheumatism.  None  had  given  him  an  idea  that  tuberculosis  was  pres- 
ent. During  his  last  illness,  for  it  proved  fatal,  he  again  suffered  to  some 
extent  from  the  same  pains.  I  have  no  doubt  that  his  pains  were  due  to 
a  neuritis  of  reflex  origin,  the  cause  being  the  tuberculous  process  in  the 
lung. 

"Mr.  G.  consulted  me  in  January,  1912,  suffering  from  a  pain  in  the 
upper  part  of  the  right  chest  which  at  first  was  considered  to  be  of  pleural 
origin.  Owing  to  my  inability  to  understand  the  patient's  language,  he 
being  a  foreigner,  I  was  somewhat  deceived  for  a  few  days.  I  found  upon 
examination  that  the  major  portion  of  the  upper  lobe  on  the  right  side 
was  involved  in  an  old  chronic  tuberculous  process  and  at  the  apex  there 
were  signs  of  cavity  formation.  His  clinical  history  was  interesting.  He 
had  always  enjoyed  good  health,  and,  being  a  man  of  means,  had  lived 
well.  In  September,  1911,  he  was  taken  suddenly  ill  with  chill  followed 
by  fever,  severe  cough,  free  expectoration  and  hemorrhages.  The  patient 
made  a  good  recovery  and  had  no  further  trouble  until  December,  1911, 
when  the  same  thing  occurred  again.  This  was  followed  in  about  two 
weeks  by  the  pain  which  I  mentioned.  The  patient  was  admitted  to  the 
sanatorium  and  carefully  watched;  the  pain  persisted,  coming  on  in  severe 
paroxysms  two  or  three  times  a  day,  sometimes  requiring  morphine.  It 
lasted  from  a  few  minutes  to  one  or  two  hours  at  a  time.  It  is  now  nearly 
six  months  since  it  started  and  it  seems  to  be  gradually  becoming  less 
severe  and  less  frequent.  The  pains  seem  to  be  confined  to  the  brachial 
plexus,  and  particularly  certain  branches  of  it;  viz.,  the  dorsalis  scapula? 
supplying  the  rhomboidei,  the  thoracales  anteriores  supplying  the  pectoralis 
minor  and  major,  the  axillaris  supplying  the  deltoideus  and  shoulder  joint. 
Many  of  the  other  branches  are  also  involved  but  these  show  the  greatest 
pain.  The  muscles  covering  the  anterior  and  posterior  surface  of  the  upper 
part  of  the  chest,  the  shoulder  and  arm  are  all  markedly  degenerated  and 
the  strength  of  the  right  arm  is  very  much  reduced. 

"It  is  very  necessary  to  recognize  these  pains,  for  they  offer 
suggestive  diagnostic  hints.  Any  of  these  pains,  especially,  if 
they  are  confined  to  one  shoulder  or  the  upper  portion  of  the 
chest,  call  for  careful  examination  of  the  lungs,  to  exclude  a 
pulmonary  involvement  before  any  other  diagnosis  is  made." 


BRACIAL     NEURITIS    AND     TUBERCULOSIS  165 

I  wish  to  append  the  two  following  cases  to  further  emphasize 
and  illustrate  the  effect  of  tuberculous  involvement  of  the  lung 
in  the  production  of  brachial  neuritis, 

Case  2422. 

Merchant,  aged  35.  Entered  the  Pottenger  Sanatorium  for  Diseases  of 
the  Lungs  and  Throat,  April  24,  1914. 

Family  History. — Mother  died  at  68,  cause  unknown.  Father,  living  and 
well.  One  brother  died  of  tuberculosis  at  the  age  of  21;  two  sisters  died 
of  tuberculosis  at  the  respective  ages  of  23  and  30  years,  all  dying  within 
a  period  of  three  months  at  the  time  the  patient  was  ten  years  old.  One 
was  ill  eight  years,  one  three  years,  and  one  a  year  and  a  half. 

Personal  History. — The  patient  was  never  strong  and  was  much  under 
weight.  He  had  the  ordinary  diseases  of  childhood  with  prompt  convales- 
cence. For  many  years  had  suffered  periodically  from  severe  hyperacidity 
and  dilatation  of  the  stomach,  but  no  definite  localized  pain.  Had  vomited 
occasionally,  the  vomitus  was  never  bloody. 

Five  years  previous  the  patient  had  suffered  an  attack  of  pleurisy  on 
the  left  side  and  on  two  or  three  occasions  had  raised  small  quantities 
of  blood,  the  amount  varying  from  a  dram  to  a  half  ounce.  The  patient 
was  examined  at  that  time  by  a  general  practitioner  and  told  that  he  had 
an  old  spot  in  the  left  lung.     The  patient  gave  this  slight  consideration. 

Several  times  during  the  past  five  years  this  patient  has  suffered  from 
hoarseness,  which  would  last  for  several  weeks  at  a  time. 

The  present  illness  began  about  a  year  and  a  half  prior  to  the  time 
of  consulting  me,  at  which  time  the  patient  developed  a  persistent  cough 
with  some  expectoration.  A  few  months  later  his  strength  declined.  '  He 
felt  tired;  his  appetite  began  to  fail;  he  also  lost  weight.  Four  months 
previously  his  throat  became  painful  on  swallowing,  and  was  especially 
irritated  by  acids.  Two  weeks  previously  he  suffered  from  attacks  of 
pleurisy  on  the  right  side.  At  times  he  raised  a  small  amount  of  blood. 
For  four  months  past  his  voice  had  been  decidedly  husky  most  of  the 
time.  Had  suffered  from  constipation  for  many  years,  apparently  of  the 
spastic  type.  Immediately  prior  to  his  entering  the  sanatorium  he  suf- 
fered from  a  very  severe  diarrhea  of  several  days'  duration. 

He  weighed  124%  pounds,  his  normal  being  145  pounds.  He  slept  fairly 
well  and  had  no  shortness  of  breath  or  night  sweats. 

Examination  at  the  Time  of  Entrance.— His  temperature  was  99.4°,  pulse 
86,  B.  P.  on  the  right  side  115-  on  the  left  95.  Complexion,  sallow;  poorly 
nourished. 

Physical  examination  of  the  chest  showed  severe  infiltration  of  the  up- 
per two-thirds  of  the  left  lung,  with  a  large  cavity  and  diffuse  infiltration 
throughout  the  entire  left  lung. 

The  right  side  showed  moderate  infiltration  of  the  upper  and  middle 
lobes  and  of  the  apex  of  the  lower  lobe. 

The  larynx  showed  marked  infiltration  of  the  arytenoids  and  inter- 
arytenoid  space  and  slight  ulceration. 

Brachial  Neuritis. — Immediately  prior  to  entering  the  institution  the  pa- 
tient had  some  pain  in  the  left  shoulder  which  became  very  severe  after 
he  had  been  in  the  institution  for  a  few  days.     The  pain  was  constant, 


166  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

and  affected  the  entire  arm,  but  was  most  severe  about  the  shoulder  and 
upper  arm.  This  pain  was  also  accompanied  by  marked  loss  of  strength 
which  involved  the  entire  arm..  The  pain  was  so  severe  that  it  was  im- 
possible for  him  to  rest  in  any  position  and  he  was  unable  to  sleep  at  night. 
The  diagnosis  of  brachial  neuritis  was  made. 

It  is  interesting  to  know  that  this  involved  the  same  side  as  the  severe 
involvement  in  the  lung.  After  a  month  the  pain  gradually  began  to  lessen 
and  in  six  weeks'  time  it  disappeared. 

Case  2375. 

Farmer,  aged  51.  Admitted  to  the  Pottenger  Sanatorium  on  November 
18,  1913. 

Family  History. — Two  brothers  died  of  tuberculosis  at  the  age  of  21  and 
23  years,  respectively,  at  the  time  patient  was  about  thirty  years  of  age. 
Patient  lived  with  brothers  during  their  illness,  but  this  was  not  the  prob- 
able source  of  infection  because,  as  will  be  seen,  the  patient  had  had 
pleurisy  thirteen  years  before. 

Tuberculous  History. — At  the  age  of  eighteen  the  patient  had  a  left- 
sided  pleurisy.  At  the  age  of  thirty-six  developed  cough  with  some  ex- 
pectoration and  about  the  same  time  had  a  hemorrhage.  Changed  resi- 
dence, going  to  some  springs,  where  he  improved  markedly  and  from  that 
time  on  had  good  health  until  1908,  when  he  contracted  what  seemed  to  be 
a  cold;  but  it  was  accompanied  by  fever  and  a  gradually  increasing  cough, 
and  was  followed  by  considerable  loss  in  weight  and  strength.  From  that 
attack  he  never  fully  recovered  and  was  unable  to  work  up  to  the  time 
he  consulted  me.  He  spent  eighteen  months  in  a  sanatorium  in  Iowa  in 
1912  and  1913.  During  his  stay  there  he  improved  and  at  the  time  he 
was  admitted  to  the  Pottenger  Sanatorium,  he  tired  easily,  had  a  capricious 
appetite,  good  digestion,  a  great  deal  of  irritation  in  the  larynx,  followed 
by  cough,  some  hoarseness,  also  some  pain  in  the  left  shoulder.  Tem- 
perature 99°,  pulse  78,  B.  P.  110,  weight  202  pounds,  which  was  about  a 
normal  weight  for  a  man  of  his  size. 

Physical  Examination. — Physical  examination  revealed  widespread  disease 
in  both  lungs.  In  the  upper  portion  of  the  left  there  was  a  suppurating 
cavity.  The  disease  was  not  very  active,  but  more  of  the  fibroid  type.  In 
the  right  lung  there  was  considerable  activity,  but  without  much  breaking 
down. 

On  discharge  from  the  sanatorium  July  21,  1914,  his  temperature  was 
99°,  pulse  82,  weight  217  pounds.  The  condition  in  both  lungs  was  markedly 
improved.  There  were  a  few  scattered  rales  throughout  the  lungs  but 
the  principal  involvement  was  confined  to  the  area  surrounding  his  cavity 
in  the  left  lung.  The  patient  was  in  good  general  condition,  and  able  to 
take  long  walks  without  tiring. 

Three  months  after  his  discharge  from  the  sanatorium  he  consulted  me 
again  in  my  city  office.  At  this  time  the  condition  in  the  lungs  was 
about  the  same,  his  general  condition  was  good,  but  he  was  suffering  from 
a  brachial  neuritis  on  the  left  side.  The  pain  was  quite  severe,  prevent- 
ing him  from  sleeping,  and  also  interfering  with  his  rest  during  the  day. 
The  muscles  of  the  left  arm  gradually  atrophied  and  the  strength  in  the 
arm  was  very  much  reduced.  This  neuritis  persisted  for  several  months 
almost  totally  disabling  the  patient. 


PATHOLOGY    OF    PERIPHERAL    NEURITIS  167 

It  is  important  to  note  that  the  brachial  neuritis  is  on  the  same  side  as  his 
severest  involvement. 

Pathology  of  Neuritis  in  the  Tuberculous. — According  to  Hezel, 
the  most  common  pathological  change  found  in  the  nerves  of 
the  tuberculous  is  a  parenchymatous  degeneration.  The  nerve 
filaments  degenerate  and  atrophy  while  the  axis  cylinder  re- 
mains intact.  In  this  early  stage  of  degeneration  no  clinical 
symptoms  are  manifest.  In  the  later  stages  of  degeneration, 
not  only  the  nerve  filaments,  but  also  the  axis  cylinder  is  in- 
volved and  conduction  is  interfered  with  and  later  may  be  wholly 
lost.  The  sheath  of  Schwann  and  the  endoneurium  show  certain 
alterations  but  nothing  that  can  be  considered  as  genuine  in- 
flammatory changes. 

In  certain  nerves  Wallerian  degeneration  takes  place.  In  a 
few  instances  which  have  been  critically  examined  the  ganglion 
cells  of  the  anterior  horn  as  well  as  the  special  ganglia  of  those 
segments  of  the  cord  from  which  the  nerves,  which  were  the  seat 
of  neuritis,  took  their  origin,  showed  histological  changes  in  the 
way  of  different  degrees  of  chromatolysis.  These  changes  were 
more  pronounced  in  the  ganglion  cells  of  the  anterior  horn  than 
they  were  in  the  cells  of  the  spinal  ganglia. 

Steinert11  found  degeneration  in  the  ascending  fibers  of  the 
spinal  cord.  The  long  fibers  of  the  posterior  column  of  the  cord 
were  degenerated.  This  was  most  marked  in  the  cervical  por- 
tion of  the  cord  and  confined  to  the  posterior  columns  of  Goll, 
the  fibers  of  the  posterior  column  which  take  their  origin  in 
the  lumbar  and  sacral  segments  of  the  cord.  The  degeneration 
of  the  ganglion  cells  in  Steinert 's  cases  was  in  the  sacral  and 
lumbar  portions  of  the  cord,  the  portions  from  which  the  dis- 
eased peripheral  nerves  took  their  origin. 

Jessen12  in  his  splendid  monograph  and  Hezel13  in  a  later  dis- 
cussion cites  the  reports  of  many  observers  showing  a  varied 
clinic  and  pathology  in  nervous  diseases,  in  which  the  tuber- 
culous process  itself  seems  to  be  the  causative  factor. 

Jessen  quotes  Heine  as  finding  degenerative  changes  in  the 
phrenics  in  27  of  29  patients  examined  and  Japp  as  finding 
changes  in  the  peripheral  nerves  of  every  one  of  15  cases. 

MZur  Kenntnis  der  Polyneuritis  der  Tuberkulosen,  Beitrage  zur  Klinik  der  Tuber- 
kulose,  vol.   ii,   1904. 

"Lungenschwindsucht  und  Nervensystem,  Gustav  Fischer,  Jena,  1905. 

"Tuberkulose  und  Nervensystem,  in  Brauer,  Schroder  und  Blumenfeld,  Handbuch  der 
Tuberkulose,  Bd.  iv,   1914. 


CHAPTER  VII. 

THE  NERVOUS  SYSTEM  CONTINUED:  THE  VEGETATIVE 
NERVOUS  SYSTEM  IN  ITS  RELATIONSHIP  TO  DIS- 
EASES   OF    THE    LUNGS:      A    DISCUSSION    OF 
PRINCIPLES,  INCLUDING  THE  ANTAGONISTIC 
ACTION  WHICH  IS  MANIFESTED  BETWEEN 
THE     GREATER    VAGUS     AND     SYMPA- 
THETIC DIVISIONS. 

Joint  Chemico-physical  Sensorimotor  and  Psychical  Control. — 

In  our  physiological  studies  the  point  is  emphasized  that  every 
cell  and  every  activity  of  the  body  is  under  the  direct  control 
of  the  nervous  system  and  subjected  to  many  reflex  influences. 
This  is  true,  but  we  must  not  forget  that  there  are  psychical 
and  chemical  controls  which  are  of  equal  importance. 

Many  viscera  produce  secretions  which  have  been  given  the 
name  of  internal  secretions  because  they  are  not  delivered  from 
the  gland  through  special  ducts,  with  which  the  gland  is  pro- 
vided ;  but  are  contained  in  the  venous  blood  as  it  emerges  from 
the  gland.  These  internal  secretions  have  selective  action;  and, 
through  them,  one  organ  may  be  able  to  control  or  influence  an- 
other organ  far  distant  in  the  body.  This  may  be  illustrated  by 
the  action  of  adrenin,  and  the  secretion  of  the  thyroid  gland,  both 
of  which  exert  influences  upon  cells  and  other  structures  through- 
out the  body.  Other  glands  produce  important  secretions  which 
have  a  more  selective  action.  All  must  work  normally  if  har- 
monious physiological  action  is  to  be  maintained  throughout  the 
body.  A  disturbance  in  one  has  a  tendency  to  produce  disturb- 
ance, either  selective  or  general  in  others,  the  same  as  is  pro- 
duced reflexly  through  the  nervous  system. 

It  is  impossible  to  definitely  separate  the  chemical  from  the 
nervous  control  of  the  body  cells.  Owing  to  our  paucity  of 
knowledge,  we  are  prevented  from  drawing  absolute  conclusions 
and  putting  the  nervous  and  chemical  control  on  an  absolutely 
scientific  basis. 


THE     VEGETATIVE     NERVOUS     SYSTEM  169 

In  any  study  that  is  to  be  made  of  the  vegetative  nervous  sys- 
tem, the  clinician  can  only  point  out  that  such  an  action  is  the 
one  that  would  be  expected  under  a  given  condition.  The  re- 
sultant action,  however,  may  be  modified  or  prevented,  by  other 
factors,  such  as  those  produced  through  an  antagonistic  reflex, 
through  chemical  control,  or  through  psychical  or  physical  in- 
fluences. 

In  this  connection  we  must  not  forget  the  psychical  control 
of  the  human  body.  The  subconscious  mind  is  always  active,  not 
only  influencing  but  determining  our  action  and  conduct,  and 
also  influencing  our  physiological  activities.  This  important  field 
is  one  that  deserves  further  study,  and  promises  to  help  us  ex- 
plain many  conditions  which  cannot  be  explained  on  a  purely 
physical  basis. 

The  Vegetative  Nervous  System. — Vegetative,  autonomic,  and 
involuntary  are  all  terms  used  to  designate  that  portion  of  the 
nervous  system  which  acts  without  the  interposition  of  the  will. 
This  system  furnishes  impulses  for  carrying  on  the  particular 
functions  of  the  body  which  are  necessary  for  the  preservation 
of  life. 

The  writer  has  been  greatly  stimulated  in  this  study  by  the 
works  of  Eppinger  and  Hess,1  Walter  B.  Cannon,2  Wm.  H.  Gas- 
kell,3  Heinrich  Higier,4  W.  v.  Bechterew,5  S.  C.  Sherrington,8 
Lewandowsky,7  Arthur  Keith,8  Biedl,9  E.  A.  Schafer,10  Chas.  E.  de 
Sajous,11  E.  H.  Starling,12  W.  M.  Bayliss,13  and  contributions  by 
Professor  E.  G-ley,  Noel  Patton,  T.  R.  Elliot,  and  Swale  Vincent, 
in  the  Practitioner's  special  number  on  " Internal  Secretions."14 

There  is  so  much  confusion  in  the  terminology  of  this  system 


1Die  Vagotonic,  Sammlung  Klinischer  Abhandlungen,  von  Noorden,  Heft.  9  u.  10, 
1910. 

2Bodily  Changes  in  Pain,  Hunger,  Fear,  and  Rage,  D.  Appleton  &  Co.,  New  York,  1915. 

3The  Involuntary  Nervous  System,  Longmans,  Green  &  Co.,  New  York,  1916. 

4Vegetative  or  Visceral  Neurology,  Ergebnisse  der  Neurologie  und  Psychiatrie,  Bd.  ii, 
Heft  1,  1912. 

°Die  Funktionen  der  Nervencentra,  vol.   i,  Gustav  Fischer,  Jena,  1908. 

"The  Integrative  Action  of  the  Nervous  System,  Charles  Scribner  &  Sons,  New  York, 
1906. 

7Die  Funktionen  des  zentralen  Nervensystems,  Gustav  Fischer,  Jena,   1907. 

8Human  Embryology  and  Morphology,  Edward  Arnold,  London,  1913. 

"Innere  Sekretion,  Urban  und  Schwartzenberg,  Wien,  1910. 

10The  Endocrine  Organs,  Longmans,  Green  &  Co.,  New  York,   1916. 

nThe  Internal  Secretions  and  the  Principles  of  Medicine,  F.  A.  Davis  and  Company, 
1903. 

12Principles  of  Human  Physiology,  Lea  and  Febiger,  1915. 

"Principles  of  General  Physiology,  Longmans,  Green  &  Co.,  New  York,  1915. 

"Practitioner,  London,  559,  vol.  xciv,  1  and  2,  January,  1915. 


170  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

and  its  divisions  that  it  is  necessary  for  each  writer  to  make 
clear  at  the  beginning  of  his  discussion  the  meaning  of  the  terms 
as  he  employs  them.  Throughout  my  discussion,  I  shall  speak 
of  the  entire  involuntary  system  as  the  vegetative  system;  and 
its  divisions  as  the  sympathetic  system,  comprising  the  motor  cells 
which  have  pushed  off  from  the  thoracic  and  upper  lumbar 
portions  of  the  cord;  and  the  greater  vagus  system,  comprising 
the  motor  cells  which  have  pushed  off  from  the  cranial,  bulbar, 
and  sacral  portions  of  the  cord. 

I  deem  it  best  to  follow  the  terminology  of  Eppinger  and  Hess 
in  calling  the  latter  group  the  "greater  vagus"  system  because 
of  the  fact  that  all  cells  belonging  to  these  groups  possess  the 
common  property  of  antagonism  to  the  sympathetic  system.  The 
greater  vagus  is  often  spoken  of  as  the  autonomic  system  (Jel- 
liffe  and  White),  in  contradistinction  to  the  sympathetic;  but, 
inasmuch  as  this  term  is  also  applicable  to  the  vegetative  system 
as  a  whole,  I  think  it  advisable  to  refrain  from  applying  it  to 
one  of  the  divisions. 

In  order  to  obtain  a  correct  idea  of  the  vegetative  nervous 
system  one  must  understand  that  the  cells  of  this  system  have 
traveled  out  from  the  central  nervous  system.  Very  early  in  em- 
bryonic life  before  the  neural  folds  have  closed  to  form  the  spinal 
cord,  these  neuroblastic  cells  migrate.  They  are  deposited  here 
and  there  and  form,  for  the  most  part,  the  ganglia  of  the  vegeta- 
tive system.  Some  of  the  neuroblastic  substance,  however,  is  de- 
posited in  other  places,  and  this  is  known  as  chromaffin  tissue; 
because,  when  stimulated,  it  secretes  a  material  which  stains 
brown  with  chrome  salts.  Physiologically,  we  know  this  secreted 
substance  as  adrenin  or  its  immediate  precursor. 

The  cells  which  migrate  from  those  portions  of  the  central 
nervous  system  which  give  origin  to  the  greater  vagus  fibers 
do  not  come  to  rest  until  they  are  situated  in  the  walls  of  the 
viscera  to  be  innervated  by  them.  Here  they  form  ganglia  and 
throw  out  their  processes  which  furnish  motor  and  secretory 
fibers.  They  are  connected  with  the  central  nervous  system  by 
connector  fibers  belonging  to  the  greater  vagus  system,  as  il- 
lustrated in  Plate  I  from  Gaskell,  which  run  from  the  centers  in 
the  cranial,  bulbar,  and  sacral  portions  of  the  central  nervous 
system  directly  to  the  ganglia  in  the  walls  of  the  viscus  sup- 


DNX  NI      NM   DNX 


B    X   Y     M    A 


Plate  I. — The  Reflex  Paths  in  the  Bulbar  Region. 

{Green — Sensory  nerve;  receptor  neuron.     Black — Connector  neuron. 
Red — Motor   nerve;    excitor    neuron.) 

A.  Of  the   Somatic  System. 

The  afferent  neurons  run  in  the  fifth  nerve,  V,  their  cells  lying  in  the  gasserian 
ganglion,  GG.  These  connect  with  the  connector  neurons  lying  close  against  the 
descending  root  of  the  fifth  nerve,  DSV.  The  connector  neurons  in  their  turn 
connect  with  the  excitor  cells  which  lie  in  the  nucleus  of  the  twelfth  nerve,  NXII. 

B.  Of  the    Splanchnic   System. 

The  receptor  neurons  run  in  the  tenth  nerve,  X,  with  their  cells  lying  in  the 
ganglion  of  this  nerve,  VG,  and  connect  with  connector  neurons  which  lie  in 
the  dorsal  nucleus  of  the  vagus,  DNX.  Processes  of  the  connector  cells  con- 
nect with  the  excitor  neurons  which  lie  in  the  nucleus  ambiguus,  NA,  their  proc- 
esses form  the  motor  part  of  the  tenth  nerve. 

C.  Of  the  Involuntary   System. 

The  receptor  neurons  run  on  the  tenth  nerve,  X,  with  their  cells  in  the  ganglion 
of  this  nerve,  VG,  and  connect  with  connector  neurons  which  lie  in  the  nucleus 
intercalatus  of  Staderini,  NI,  which  forms  a  part  of  the  dorsal  nucleus  of  the 
vagus,  DNX.  The  processes  of  these  connector  neurons  run  out  in  the  vagus 
nerve,  X,  and  finally  connect  with  the  excitor  neuron  which  lies  on  some  peripheral 
organ;   e.g.,   in  the   case   of   the  intestine   lying  in   Auerbach's   plexus,   AP. 

(Gaskell.) 


VEGETATIVE     NERVOUS     SYSTEM 


171 


Tear  Gland. 
Dilator  of  Pwnif 

drteru  of  saArdrt/ 

Sur/ace  artery 
SweaT  9  fan  ct  ■ 


Heart 

Hair- 
Surface  artery 
S  lAreat  <y  Iqnct 

L/iser- 

St~o  mac  A. 


^f  Viscera)  artery 


Jntes  tine. 


/Id r  eh  3?  Q?ah  d 

Ha.r- 

Surf^ce   artery 


Artery  of  externit) 
cfenitc)  Is  . 

Fig.  24. — Illustrating  schematically  the  vegetative  nervous  system,  showing  the  fact 
that  all  the  internal  viscera  are  doubly  innervated  by  fibers  coming  from  the  thoraco- 
lumbar or  sympathetic  division,  and  the  cranial  bulbar  and  sacral,  or  greater  vagus  division 
(Lannon.)  The  bronchi  have  been  omitted  from  this  scheme  but  should  show  as  re- 
ceiving sympathetic  fibers  from  the  upper  six  thoracic  segments,  and  greater  vagus  fibers 
from  the  vagus  nerve. 


172 


NERVOUS  SYSTEM  IN  TUBERCULOSIS 


plied.    There  are  no  ganglia  on  their  paths.    The  scheme  of  the 
vegetative  nervous  system  is  shown  in  Fig.  24. 

In  the  sympathetic  system,  the  arrangement  of  these  neuro- 
blastic  cells  is  different.  As  they  wander  out  from  the  cord  they 
are  deposited  in  various  places.  First,  there  is  a  clump  in 
front  of  each  segment  of  the  cord  which,  when  joined  together, 
make  up  the  ganglionated  cord  of  the  sympathetic  system.  Then, 
there  are  other  clumps  here  and  there  between  the  ganglionated 
cord   and  the   viscera   supplied.     These   clumps   constitute   the 


Fig.  25. — Illustrating  schematically  the  course  of  the  fibers  in  the  sympathetic  nervous 
system.  Gi,  vertebral  ganglion;  G2,  prevertebral  sympathetic  ganglion;  H,  skin;  E,  inter- 
nal viscus;  a,  anterior  root  of  the  cord;  p,  posterior  root  of  the  cord;  S,  sensory  nerve; 
Ra,  ramus  albus;  Rg,  ramus  griseus;  Sy,  ganglionated  cord  of  the  sympathetic.  (Iyewand- 
owsky.) 

ganglia  of  the  sympathetic  nervous  system.  From  them,  fibers 
pass  to  form  plexuses  before  going  to  the  parts  innervated. 
These  ganglia  are  connected  with  each  other  so  intimately  as  to 
make  the  stimulation  of  the  sympathetic  nervous  system  more 
or  less  general  throughout  all  the  parts  supplied  by  it.  The  re- 
ceptor neurons  of  the  sympathetic  system  run  in  the  posterior 
root  where  they  connect  with  their  cells.  These  are  connected 
with  the  sympathetic  ganglia  by  connector  neurons  which  lie 
in  the  lateral  horn  and  throw  out  processes  which  pass  through 
the  anterior  root  as  the  white  rami.    This  is  illustrated  in  Plates 


Plate  II.- — The  Reflex  Paths  in  the   Cord. 

{Green — Sensory     nerve;     receptor     neuron.       Black — Connector    neuron. 
Red — Motor  nerve;   excitor  neuron.) 

A.  Of  the  Voluntary   System. 

The  receptor  neurons  run  in  the  posterior  root,  their  cells  lying  in  the  posterior 
root  ganglion,  PRG.  The  connector  neurons  lie  in  the  dorsal  horn,  DH,  and  con- 
nect with  the  excitor  neurons  lying  in  the  ventral  horn,  VH,  whose  processes 
run   in   the    anterior    root. 

B.  Of   the   Involuntary    System. 

The  receptor  neurons  run  in  the  posterior  root,  their  cells  lying  in  the  posterior 
root  ganglion,  PRG.  The  connector  neurons  lie  in  the  lateral  horn,  LH,  their 
processes  running  out  in  the  anterior  with  the  excitor  neurons  lying  in  the 
sympathetic  ganglia,  SyG.  The  processes  of  the  excitor  neurons  form  the  gray 
ramus   communicans  and   run   out  in   the  spinal  nerve. 


SYMPATHETIC     NERVOUS     SYSTEM  173 

I  and  II  from  Gaskell.  This  whole  sympathetic  ganglionated  sys- 
tem, however,  is  connected  with  the  central  nervous  system  by  con- 
nector fibers,  one  going  from  each  segment  of  the  thoracic  and 
upper  lumbar  portions  of  the  cord  to  the  ganglion  of  the  gan- 
glionated cord  lying  immediately  adjacent  to  it.  The  sympa- 
thetic filaments  follow  the  blood  vessels  in  their  entrance  to  the 
organ.  The  scheme  of  the  reflex  path  to  the  cord  is  shown  in 
Fig.  25. 

These  clumps  of  neuroblasts  tissue  given  off  from  the  thoracic 
and  upper  lumbar  portions  of  the  cord,  which  do  not  go  to  make 
up  sympathetic  ganglia,  are  deposited  in  various  places  and  to- 
gether make  up  the  chromaffin  system  of  the  body.  The  prin- 
cipal point  of  chromaffin  deposit  in  man  is  in  the  medulla  of 
the  suprarenal  gland.  It  is  also  found  at  the  branching  of  the 
carotids,  and  the  branching  of  the  aorta. 

The  portion  of  the  chromaffin  system  which  interests  us  most 
in  our  study  is  that  found  in  the  adrenal  gland.  It  will  be  seen 
from  this  description  of  the  development  of  the  sympathetic 
system  that  the  chromaffin  tissue  is  an  integral  part  of  that  sys- 
tem. This  relationship  is  also  shown  physiologically.  The  se- 
cretion produced  by  it,  adrenin,  acts  upon  all  structures  of  the 
body  supplied  by  the  sympathetic  nervous  system,  and  produces 
the  same  action  as  though  the  sympathetic  system  was  stimulated 
centrally.  The  place  of  action  of  adrenin,  however,  is  exerted 
at  the  myo-neural  junction  of  the  organ  innervated  by  the  sym- 
pathetic system,  instead  of  on  central  cells.  The  resemblance 
of  the  chromaffin  tissue  found  in  the  medulla  of  the  adrenal 
gland  to  the  sympathetic  ganglia  is  shown  in  another  way.  It 
has  direct  connector  fibers  with  the  cord,  the  same  as  ganglia 
which  make  up  the  ganglionated  cord;  consequently,  every  cen- 
tral stimulation  of  the  sympathetic  nervous  system  stimulates 
the  adrenal  gland,  causing  it  to  secrete  adrenin.  The  stimulus 
passes  directly  to  the  gland,  instead  of  passing  through  the 
ganglionated  cord,  as  do  the  stimuli  through  the  sympathetic 
system  to  the  other  internal  viscera.  In  this  respect  its  innerva- 
tion is  like  that  of  the  greater  vagus  system;  but  it  is  unlike  it 
because  the  system  itself  must  be  considered  as  a  part  of  the 
sympathetic  system. 

The  sympathetic  cells  come  from  the  thoracic  and  upper  lum- 


174  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

bar  segments  of  the  cord  and  go  to  every  portion  of  the  body. 
They  supply  not  only  every  internal  viscus,  but  the  entire  epi- 
dermal musculature,  including  the  pilomotor  muscles  and  the 
muscles  of  the  sweat  glands;  and  also  furnish  vasoconstrictor 
fibers  to  the  blood  vessels  throughout  the  entire  body. 

From  the  interposition  of  numerous  ganglia  which  modify  and 
divert  impulses  it  can  be  seen  that  a  sympathetic  impulse  is 
much  more  general  in  its  action  than  a  vagus  impulse.  Central 
influences  such  as  stimulation  produced  by  toxins,  and  that  pro- 
duced by  the  depressive  emotional  states,  likewise  peripheral  stim- 
ulation by  such  chemical  substances  as  adrenin,  act  generally, 
influencing  many  of  the  body  structures  at  the  same  time. 

The  greater  vagus  system,  however,  is  different  in  that  its 
action  is  more  selective.  It  is  possible  to  have  a  stimulation 
which  affects  only  the  connector  fibers  between  the  central  nerv- 
ous system  and  the  heart,  or  the  stomach,  or  the  eye,  or  the 
pelvic  organs,  leaving  the  others  uninfluenced.  In  this  system, 
however,  if  we  find  marked  vagus  stimulation  in  one  organ,  we 
are  apt  to  find  evidence  of  it  in  others. 

The  Inhibitory  Action  of  Visceral  Nerves. — The  inhibitory  ac- 
tion of  the  visceral  nerves  is  not  thoroughly  understood  and 
causes  considerable  confusion.  It  seems  that  when  the  nerve  cell 
which  gives  origin  to  motor  nerves  to  the  endodermal  muscula- 
ture, traveled  out  from  the  central  nervous  system,  that  it  also, 
at  the  same  time,  gave  off  an  inhibitory  filament  to  opposing  mus- 
culature. In  many  instances,  from  definite  physiological  experi- 
ment and  discovery  we  cannot  say  that  there  are  inhibitory 
nerves;  but,  from  clinical  observation  of  physiological  action  we 
know  that  such  must  be  the  case.  There  seems  to  be  very  widely 
distributed  indications  of  reciprocal  innervation  between  the 
greater  vagus  and  sympathetic  systems.  The  motor  cells  of  the 
greater  vagus,  whether  in  the  lungs  or  in  the  liver,  or  in  the  small 
or  large  intestine,  lie  in  the  muscles  themselves,  and  their  in- 
hibitory nerves  come  from  the  cells  of  the  sympathetic  system. 
Other  portions  of  the  gastrointestinal  tract,  such  as  the  esophagus 
and  pharynx,  offer  probable  exceptions  to  this.  Some  physiolo- 
gists, however,  claim  that  this  same  antagonistic  action  exists  in 
the  esophagus. 


STRUCTURES  SUPPLIED  BY  SYMPATHETIC  AND  GREATER  VAGUS  175 

Grouping  of  Structures  Supplied  by  the  Sympathetic  and 
Greater  Vagus  Systems. — Adrenin  is  a  product  of  the  chromaffin 
cells  of  the  body  which  in  lower  life,  were  closely  associated  with 
the  cells  of  the  sympathetic  nervous  system ;  consequently,  in  the 
higher  animals,  adrenin  acts  chemically,  and  produces  the  same 
effect  as  central  stimulation  of  the  sympathetic  cells.  Acetyl- 
choline, on  the  other  hand,  produces  the  same  effect  when  in- 
troduced into  the  body  as  stimulation  of  the  greater  vagus  divi- 
sion of  the  vegetative  system;  consequently,  structures  reacting 
to  adrenin  are  considered  as  deriving  their  nerve  supply  from 
the  sympathetic  system,  while  those  reacting  to  acetyl-choline 
derive  their  supply  from  the  greater  vagus. 

There  is  also  a  pharmacological  test  which  is  of  great  value 
in  differentiating  sympathetic  and  greater  vagus  innervation. 
Atropin,  when  introduced  into  the  body,  counteracts  the  action 
produced  by  stimulation  of  the  greater  vagus  and  produces  the 
same  effect  as  that  which  is  produced  by  sympathetic  stimula- 
tion. Pilocarpin,  on  the  other  hand,  produces  the  same  effect  as 
stimulation  of  the  greater  vagus ;  consequently,  it  counteracts  the 
action  of  the  sympathetics ;  so  with  adrenin  and  acetyl-choline; 
atropin  and  pilocarpin,  we  can  go  far  toward  determining  which 
division  of  the  vegetative  nervous  system  produces  a  given 
symptom.  In  this  connection  I  would  mention  that  physiologi- 
cally, we  are  led  to  believe  that  sweat  is  produced  by  sympathetic 
stimulation  ;  but  pharmacologically, — that  is,  by  the  use  of 
atropin,  we  find  that  sweating  is  counteracted;  and  this  would 
indicate  that  sweat  secretion  is  a  greater  vagus  effect,  rather  than 
sympathetic.     It  is  probable  that  it  may  be  both. 

The  unstriped  muscles  of  the  body  may  be  divided  as  follows, 
according  to  Gaskell.15 

1.  The  vascular  group.  Every  vessel  throughout  the  body 
is  supplied  by  the  sympathetic  nervous  system.  The  nerves  sup- 
plying the  blood  vessels  take  their  origin  from  the  entire  sym- 
pathetic area,  which  extends  from  the  first  thoracic  to  the  fourth 
lumbar  segments.  In  every  instance  motor  cells  to  the  blood 
vessels  of  any  organ  are  found  in  the  ganglia  which  supplies  the 
organ  itself  with  sympathetic  nerves. 

2.  The  group  of  muscles  underlying  the  skin  or  epidermis. 


15The  Involuntary  Nervous  System,  Longmans,  Green  &  Co.,  New  York,  1916. 


176  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

This  includes  the  muscles  to  the  sweat  glands  and  the  pilomotor 
muscles,  which,  when  stimulated,  cause  erection  of  the  hair. 

3.  The  group  of  muscles  underlying  the  surface  of  the  gut  or 
endoderm. 

4.  The  group  of  muscles  around  the  segmental  duct,  which  in- 
cludes the  Wolffian  ducts,  or  urinary  system,  and  the  Mullerian 
ducts,  or  generative  system. 

5.  The  group  of  muscles  forming  that  part  of  the  gut  wall, 
which  particularly  constitutes  the  sphincter  muscles.  Among 
these  are  included  the  ileo-colic  sphincter,  the  internal  anal 
sphincter,  and  the  internal  vesicle  sphincter.  The  cardiac 
sphincter  seems  to  be  supplied  by  the  vagus,  while  the  pylorus 
is  supplied  by  both  the  vagus  and  sympathetic. 

6.  The  group  of  muscles  connected  with  the  adjustment  of 
vision.  These  are  the  muscles  which  supply  the  ciliary  muscle, 
the  ciliary  body,  the  Mullerian  muscle ;  and  palpebral  muscles. 

Groups  1,  2,  4,  and  5,  are  supplied  by  the  sympathetic  nervous 
system  wholly,  while  groups  3  and  6  are  supplied  by  the  greater 
vagus. 

Aside  from  this  particular  division  of  the  unstriped  muscles 
of  the  body,  according  to  their  innervation,  all  internal  viscera 
are  likewise  supplied  by  both  the  greater  vagus  and  the  sym- 
pathetic divisions  of  the  vegetative  system.  "Wherever  the  sym- 
pathetic and  the  greater  vagus  systems  meet  they  are  antago- 
nistic to  each  other. 

Symptoms  Due  to  Stimulation  of  Vegetative  Nerves  are 
Variable. — It  would  give  a  wrong  impression  to  indicate  that 
we  can  with  our  present  knowledge,  follow  out  and  accurately 
tell  what  symptoms  will  be  produced  by  stimulation  of  the 
vagus  nerves,  and  what  by  the  sympathetic  nerves;  or  tell 
what  symptoms  will  be  produced  by  this  internal  secretion,  or 
that  internal  secretion;  because  other  factors  are  active  at  the 
same  time.  We  can  only  tell  what  the  symptom  would  be  if 
one  factor  were  operating  alone.  Normally,  we  might  have  a 
stimulation  of  the  vagus  filament  going  to  the  heart,  Avhich  would 
be  sufficient  to  produce  a  slowing  of  the  heart's  action;  but, 
there  might  be,  counteracting  this,  either  a  central  stimulation 
of  the  sympathetic  system  caused  by  toxemia,  or  a  peripheral 


EXPLANATION  FOR  VARIABILITY  OF  SYMPTOMS  177 

stimulation  caused  by  adrenin  or  other  internal  secretions  which 
act  upon  the  sympathetics  being  thrown  into  the  blood  and 
irritating  the  sympathetic  fibers  which  go  to  the  heart,  or  an 
increased  demand  for  oxygen  on  the  part  of  the  tissues  which 
requires  increased  heart  action,  overcoming  the  slowing  effect 
of  the  vagus.  Or,  I  might  cite  as  another  illustration,  a  condition 
which  we  often  see  where  a  pulmonary  tuberculosis  is  complicated 
by  an  intestinal  infection.  This  complication  is  nearly  always 
associated  with  considerable  toxemia.  Fever  is  a  common  symp- 
tom. Eapid  heart's  action  should  be  an  accompaniment  of 
the  toxemia.  The  heart's  action,  naturally,  increases  at  a  certain 
rate  for  a  certain  degree  of  toxemia,  as  indicated  by  the  temper- 
ature curve;  but  where  an  organ  supplied  by  the  vagus  is  in- 
volved, there  may  be  such  a  strong  stimulation  of  the  nerve 
endings  of  the  vagus  that  a  reflex  decrease  in  the  pulse  rate 
is  found.  This  often  occurs  in  intestinal  inflammation  in  spite 
of  the  fact  that  toxemia  is  accompanied  by  an  increase  of 
adrenal  secretion;  and,  in  spite  of  the  fact  that  nearly  all  pa- 
tients who  have  an  intestinal  involvement,  suffer  from  more 
or  less  nerve  depression,  which,  of  itself,  acts  through  the 
sympathetic,  and  has  a  further  tendency  to  increase  sympa- 
thetic stimulation.  However,  an  understanding  of  the  antagonistic 
action  of  the  two  divisions  of  the  vegetative  system,  and  an  ap- 
preciation of  the  fact  that  the  tonus  of  these  two  divisions 
differs  in  different  individuals ;  and  a  further  appreciation  of  the 
fact  that  both  systems  might  be  stimulated  and  yet  the  resultant 
action  be  due  to  the  irritation  of  one  of  them  predominating, 
will  help  greatly  in  the  interpretation  of  symptoms. 

Segmentation  of  the  Body. — In  order  to  understand  the  symp- 
tomatology of  an  infectious  disease  located  in  an  internal  organ, 
it  is  necessary  to  understand  the  nerve  supply  of  that  organ. 
In  order  to  understand  the  nerve  supply  it  is  necessary  to  call 
upon  our  knowledge  of  embryology,  and  this  brings  us  face  to 
face  with  two  of  the  most  difficult  subjects  in  physiology, — em- 
bryology and  visceral  neurology. 

There  are  certain  pains  distant  from  the  seat  of  inflammation 
which  have  long  been  recognized  in  medicine,  such  as  pain  in 
the  shoulder,  accompanying  an  inflammation  of  the  central  por- 


178 


NERVOUS  SYSTEM  IN  TUBERCULOSIS 


tion  of  the  diaphragm,  and  pain  in  the  left  arm  in  diseases  of 
the  heart.  Unless  one  has  studied  evolution  from  the  lower  forms 
of  life,  and  the  development  of  the  human  embryo,  these  symptoms 
are  difficult  to  explain;  but,  when  one  is  conversant  with  these 
subjects  and  understands  the  developmental  relations,  he  can 
readily  furnish  an  explanation  for  them. 

In  the  early  stages  of  evolution  the  body  was  made  up  of 
many  similar  segments  joined  together.  In  the  simpler  forms 
the  segments  were  similar  and  had  similar  functions.  As  evolu- 
tion proceeded,  a  differentiation  of  segments  took  place  in  order 


D.TC 


D.SSL 


s.-&- 


Fig.  26. — Diagram  of  a  human  embryo,  fifth  week,  showing  the  arrangement  and  ex- 
tension of  the  mesoblastic  segments.  The  first  and  last  of  each  segment  entering  into  the 
formation  of  the  limbs  is  stippled  (C.V  to  D.II  and  L.I  to  S.III).  The  position  is  indi- 
cated in  which  the  sternum  is  formed.      (A.   M.   Patterson.) 

to  form  the  different  parts  of  the  body.  In  the  adult  human 
body  this  differentiation  is  carried  so  far  that  it  is  necessary 
to  return  to  the  study  of  the  embryo  in  order  to  grasp  the 
similarity  of  the  different  segments  (see  Fig.  26). 

The  human  body  consists  of  thirty-three  or  thirty-four  seg- 
ments, fundamentally  the  same,  but  modified  to  form  the  cervical, 
thoracic,  lumbar,  sacral,  and  caudal  regions  of  the  body.  These 
segments,  or  somites  as  they  are  called,  consist  of  several  struc- 
tures :  1,  skeletal ;  2,  muscular ;  3,  arterial ;  and  4,  nervous. 

It  is  an  important  fact,  from  the  standpoint  of  the  diagnos- 


SEGMENTAL  RELATIONSHIP   OF  BODY  STRUCTURES  179 

tician  to  know  that  segmentation  of  the  cord  also  takes  place. 
From  each  segment  of  the  thoracic  and  upper  portions  of  the 
cord,  four  groups  of  cells  arise:  1,  somatic  motor;  2,  somatic 
sensory;  3,  splanchnic  motor;  and  4,  splanchnic  sensory.  The 
somatic  motor  group  is  situated  in  the  anterior  horn.  It  sends 
out  processes  to  all  the  somatic  muscles  of  the  primitive 
segment  in  which  it  is  situated.  The  splanchnic  motor  cells 
are  found  in  the  lateral  horn  and  send  out  processes  which 
reach  the  viscera  belonging  to  the  given  segment  through 
the  white  rami  cominunicantes  and  sympathetic  system.  The 
somatic  sensory  group  is  found  in  each  segment.  It  forms  the 
posterior  root  ganglia;  and  from  within  this,  neuroblasts  bi- 
furcate and  send  out  processes,  one  of  which  extends  into  the 
posterior  horn,  while  the  other  goes  to  the  skin,  muscles,  and 
subcutaneous  tissue  of  the  segment.  The  splanchnic  sensory 
group  is  situated  in  the  posterior  root  ganglia  and  also  in  the 
ganglia  of  the  sympathetic.  This  sensory  group  connects  the 
internal  viscera  with  the  cord  in  such  a  manner  that  each  viscus 
or  part  of  a  viscus  is  connected  with  some  certain  segment  of  the 
cord. 

These  physiological  facts  relative  to  segmentation  are  of  the 
utmost  importance  to  clinicians;  for  whenever  any  portion  of 
a  body  segment  is  diseased,  the  cells  of  the  corresponding  seg- 
ment of  the  spinal  cord  are  disturbed.  This  is  of  the  greatest 
importance  in  the  diagnosis  of  inflammation  of  the  internal  viscera; 
for  each  viscus,  or  part  of  a  viscus,  is  in  reflex  connection  through 
the  spinal  cord  with  that  area  on  the  surface  of  the  body  which 
takes  its  nerve  supply  from  the  same  segment  of  the  cord. 

Segmental  Relationship  of  the  Lungs.— Head16  pointed  out  that 
there  were  certain  areas  in  the  skin  which  showed  trophic 
change  and  altered  reaction  to  pain,  heat,  and  cold,  when  the 
lung  is  inflamed. 

The  writer  has  called  attention  in  numerous  papers  since  1909 
to  the  spasm  of  the  neck  and  chest  muscles  which  occurs  when 
the  pulmonary  parenchyma  is  acutely  inflamed  and  to  a  de- 
generation of  the  muscles,  subcutaneous  tissue  and  skin  which 
takes  place  when  this  inflammation  becomes  chronic,  or  heals  after 
being  present  for  a  long  time.     The  motor  reflex  which  I  have 


16Brain,  vol.  xvi,   1893. 


180  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

described  clinically  has  not  been  described,  to  my  knowledge, 
by  the  physiologist. 

The  lung  is  supplied  by  the  sympathetic  fibers  from  the  upper 
six  dorsal  segments  which  proceed  principally  from  the  stellate 
ganglion.  The  stellate  ganglion  is  made  up  of  fibers  from  the 
upper  three  or  four  dorsal  ganglia.  The  lung  also  receives  vagus 
fibers  coming  from  the  bulbar  roots.  The  fibers  from  the  vagus 
supply  the  mucous  glands  and  the  musculature  of  the  bronchus 
and  produce  increased  secretion  and  increased  muscular  tone, 
when  stimulated.  The  fibers  of  the  sympathetic  counteract  the 
vagus  and  check  secretion  and  produce  relaxation  of  the  bronchial 
walls  and  a  reduction  in  bronchial  secretion,  when  stimulated; 
consequently,  such  measures  as  will  effect  a  sympathetic  stim- 
ulation have  a  tendency  to  overcome  bronchial  asthma.  This 
is  the  action  of  the  adrenalin  and  atropin.  It  also  explains  the 
observation  which  I  have  made  in  several  cases  where  attacks 
of  acute  toxemia,  through  their  stimulation  of  the  sympathetics, 
relieved  attacks  of  bronchial  asthma.  One  of  my  patients  was 
suffering  severely  from  asthma,  when  he  was  given  a  dose  of 
tuberculin  which  caused  a  toxic  reaction.  His  asthma  was 
slightly  reduced  in  severity  by  the  stimulation  caused  by  the  tox- 
emia. The  same  patient  had  previously  experienced  freedom 
from  asthma  during  a  fever  reaction  caused  by  severe  physical 
exertion. 

The  afferent  fibers  passing  from  the  lung  to  the  periphery  do 
not  take  the  same  course  as  they  do  in  the  lower  segment  of 
the  cord,  where  they  pass  directly  to  the  segment  from  which 
the  impulse  arises.  Afferent  impulses  from  the  lungs  pass  to 
the  cervical  ganglia  and  there  communicate  through  the  gray 
rami  with  the  cervical  segments  of  the  cord.  The  superior 
cervical  ganglion  communicates  with  the  first,  second,  third 
and  fourth  cervical  segments;  the  middle  ganglion,  or  the  con- 
necting cord,  in  its  absence,  communicates  with  the  fifth  and 
sixth  cervical  segments,  and  the  inferior  ganglion  with  the 
seventh  and  eighth  cervical  segments.  Thus  it  will  be  seen  that 
there  is  an  intimate  connection  between  the  lung  and  the 
cervical  segments  of  the  cord.  Inflammation  of  the  lung  tissue, 
sending  impulses  centralwards,  disturbs  the  nerve  cells  of  this 


PULMONARY  REFLEXES  IN  SUPERFICIAL  STRUCTURES  181 

portion  of  the  cord  and  causes  motor,  sensory,  and  trophic  stimuli 
to  pass  peripherally  to  those  parts  which  are  innervated  from 
these  segments.  Thus  we  have  sensory  disturbances  more  or 
less  general  throughout  the  cervical  zones  (Head),  and  motor 
disturbances  throughout  the  somatic  muscles,  and  trophic  changes 
in  all  the  tissues  which  take  their  innervation  from  this  portion 
of  the  cord  (Pottenger).  While  there  are  no  sympathetic  fibers 
which  originate  in  the  cervical  portion  of  the  cord,  yet  all 
cervical  segments  are  connected  with  the  afferent  impulses  which 
proceed  from  the  lung. 

Many  writers  have  denied  that  the  lung  has  sensation.  From 
this  we  have  been  led  to  infer  that  there  could  be  no  reflexes 
in  the  somatic  areas  which  are  connected  with  the  lung.  This, 
however,  has  been  shown  to  be  untrue  both  by  the  work  of  Head 
and  that  of  the  writer. 

Different  segments  of  the  cervical  cord  seem  to  receive  im- 
pulses from  the  lung  in  varying  degree.  The  point  which  seems 
to  be  particularly  the  center  of  bombardment  is  the  third  and 
fourth  cervical  segments.  These  segments  supply  nerve  energy 
to  the  important  muscles  of  the  neck  and  chest  including  the 
diaphragm  (all  important  muscles  of  respiration)  and,  through 
this  fact,  spasm  of  these  muscles  becomes  an  important  symptom 
in  inflammation  of  the  lung.    See  table  of  muscles,  page  330. 

Head  has  also  shown  that  the  third  and  fourth  cervical  seg- 
ments are  the  ones  that  are  particularly  prone  to  show  the 
sensory  disturbances  when  the  lung  is  involved.  We  also  have 
segmental  sensory  disturbances  in  the  thoracic  portions  of  the 
cord,  in  which  the  fourth  and  fifth  thoracic  zones  are  the  chief 
centers  of  the  impulse.  For  the  location  of  these  zones  see 
Figs.  27  and  28,  pages  182  and  183. 

Lungs  Embryologically  Formed  From  Intestine. — In  order  to 
discuss  the  reflex  symptoms  which  occur  in  pulmonary  tuber- 
culosis it  is  necessary  to  understand  that  the  lungs  were  formed 
embryologically  from  a  diverticulum  of  the  intestine,  conse- 
quently, they  carry  with  them  the  same  innervation  as  the  in- 
testine from  which  they  are  derived.  They  have  involutary  mus- 
culature the  same  as  that  in  the  pharynx  and  esophagus  and  re- 
ceive motor  fibers  from  the  motor  cells  of  the  nucleus  ambiguus  in 


182 


NERVOUS  SYSTEM  IN  TUBERCULOSIS 


Cerv.  4 


Thorac.  2 


Cerv.   3 


Thorac.  5 


Cerv.  5 


Fig.  27. — Head's  zones.     (Anterior  surface  of  the  chest  and  abdomen.) 


the  medulla  oblongata.  The  involuntary  musculature  surrounding 
the  bronchi  receives  its  fibers  from  the  motor  cells  in  the  lungs 
themselves,  these  cells  receiving  connector  fibers  from  the  vagus. 


HEAD  S    ZONES 


183 


Cerv.  3- 


Cerv.  5 
Thorac.  1 


Thorac.  3- 


Thorac.  9 


Thorac.  11. 


Cerv.  7. 


Thorac.  2 


Thorac.  4 


Fig.  28. — Head's  zones.     (Posterior  surface  of  the  body.) 

The  Relation  of  Symptoms  in  Tuberculosis  to  the  Greater  Vagus 
and  Sympathetic  Divisions  of  the  Vegetative  Nervous  System. — In 
studying  the  clinical  history  and  symptom-complex  of  pulmonary 


184  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

tuberculosis,  everyone  must  have  been  more  or  less  impressed 
with  the  indefiniteness  of  the  symptoms  and  signs  connected  with 
this  disease. 

There  are  some  twenty-five  or  thirty  different  symptoms  which 
accompany  early  tuberculosis,  and  even  more  in  advanced  tuber- 
culosis; and  if  we  think  of  each  symptom  as  an  individual  entity, 
there  is  no  end  of  confusion.  By  carefully  studying  these  various 
symptoms  I  have  found  that  etiologically  they  belong  to  three 
groups,  as  shown  on  page  366.  I  first  published  this  classification 
two  years  ago17  but  I  can  see  even  more  clearly  than  I  did  at  that 
time  the  great  value  of  this  etiological  study.  By  knowing  the 
causes  operating,  we  understand  the  reason  for  their  variability. 

This  classification  was  arrived  at  after  several  years  of  study, 
during  which  time  I  was  endeavoring  to  find  an  explanation  for 
various  reflex  actions  which  were  observed  clinically.  The  study 
has  been  difficult  because  of  the  fact  that  its  very  foundation 
is  surrounded  by  uncertainty.  It  was  necessary,  in  many  in- 
stances, to  reason  from  effect  to  cause, — after  noting  the  reflex 
action,  to  find  its  path.  Later,  however,  after  becoming  more 
conversant  with  the  vegetative  nervous  system  and  its  vagaries, 
I  was  able  to  determine  that  certain  action  in  various  structures 
should  result  from  the  stimulation  of  the  pulmonary  endings 
of  the  greater  vagus  and  the  sympathetic  systems ;  and,  in  many 
instances,  I  have  been  able  to  find  this  to  be  the  case. 

The  division  of  symptoms  into  groups,  according  to  their 
etiology,  has  proved  of  great  practical  value  in  helping  the  ex- 
aminer to  weigh  the  importance  of  the  symptoms  which  present 
in  a  given  case;  but  there  still  remained  other  facts  equally  im- 
portant to  be  determined.  I  then  set  for  myself  the  task  of  going 
deeper  into  the  etiology  of  these  etiological  groups  to  see  if  we 
could  tell  why  toxemia  produces  malaise,  a  feeling  of  being  run 
down,  lack  of  endurance,  loss  of  strength,  nervous  instability, 
digestive  disturbances,  loss  of  weight,  increased  pulse  rate,  night 
sweats,  fever,  and  anemia;  and  how  reflex  action  produces  hoarse- 
ness, tickling  in  the  larynx,  cough,  digestive  disturbances,  loss 
of  weight,  circulatory  disturbances,   chest  and  shoulder  pains, 


17Some  Practical   Points  in  the  Diagnosis  of  Active  Tuberculosis,   Northwest  Medicine, 
January,    1914. 


GROUPING   OP  SYMPTOMS  185 

flushing  of  the  face,  and  apparent  anemia;  and  why  the  symp- 
toms of  Group  II  are  so  variable. 

The  explanation  to  my  first  question  came  after  and  through 
finding  the  explanation  for  my  second  and  third.  I  saw  that 
the  symptoms  of  Group  II  were  due  to  action  through  two 
divisions  of  the  vegetative  system,  the  greater  vagus  and  the 
sympathetic ;  and,  that  their  variability  depended  on  the  fact  that 
these  two  divisions  are  antagonistic  in  action  wherever  they 
meet  in  the  same  organ  and  that  the  relative  tonus  of  the  two 
divisions  differs  in  diffent  individuals  and  at  different  times. 
I  then  saw  that  the  symptoms  on  the  part  of  the  various  viscera 
which  were  produced  from  stimulation  of  the  sympathetics  are 
the  same  as  the  visceral  symptoms  due  to  toxemia.  This  gave 
the  clue  that  the  toxic  group  of  symptoms  in  tuberculosis  is 
produced  by  stimulation  of  the  central  nerve  cells  and  that  it 
expresses  itself  particularly  through  the  sympathetics  as  a  gen- 
eral inhibition  of  function  on  the  part  of  the  internal  viscera18 
as  dealt  with  more  fully  in  Chapter  VIII. 

In  this  discussion  I  desire  to  treat  at  some  length  the  subject 
of  the  antagonistic  action  between  the  greater  vagus  and  the 
sympathetic  divisions  of  the  vegetative  nervous  system,  and  show 
how  this  becomes  a  factor  of  great  importance  in  determining 
not  only  the  character  of,  but  the  presence  of  symptoms  which 
are  due  either  to  central  or  peripheral  stimulation  of  the  pul- 
monary filaments  of  the  vagus  and  sympathetic  systems  by  the 
tuberculous  inflammation  in  the  lung. 

The  vegetative  nervous  system  supplies  impulses  to,  as  pre- 
viously mentioned,  smooth  muscles,  such  as  the  stomach,  intestines, 
blood  vessels,  ducts  of  glands,  skin,  and  secreting  glands;  also  to 
certain  organs  possessing  striated  muscle  fibers,  such  as  the  heart, 
the  beginning  and  terminal  portions  of  the  alimentary  canal,  and 
the  generative  organs. 

This  system  is  characterized  by  the  fact  that  under  no  circum- 


18Pottenger :  The  Early  Pathological  Changes  and  Their  Relationship  to  Clinical  Symp- 
toms and  Physical  Signs  in  Pulmonary  Tuberculosis,  Southwest  Journal  of  Medicine  and 
Surgery,  November,  1915;  Clinical  Symptoms  and  Physical  Signs  in  the  Early  Diagnosis 
of  Pulmonary  Tuberculosis:  A  Discussion  from  the  Standpoint  of  Their  Etiology  and 
Their  Relationship  to  Each  Other,  Read  Before  the  Robert  Koch  Society,  Chicago,  Il- 
linois, October  18,  1915,  Illinois  Medical  Journal,  January,  1916;  The  Syndrome  of 
Toxemia:  An  Expression  of  General  Nervous  Discharge  Through  the  Sympathetic  Ner- 
vous System,  Journal  American  Medical  Association,  January  8,   1916. 


186  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

stances  do  organs  or  parts  receive  innervation  directly  from  a 
neuron  whose  cell  bodies  lie  in  the  brain  or  spinal  cord.  Ganglia 
are  interposed  between  the  nerve  cells  in  the  central  nervous 
system  and  the  part  innervated,  which  act,  most  probably,  by  modi- 
fying impulses.  In  these  ganglia  are  cell  bodies  belonging  to 
neurons  which  carry  impulses  on  toward  the  part  innervated, 
although  they  have  no  direct  connection  with  the  central  nervous 
system.  These  outlying  neurons  have  preganglionic  fibers  which 
connect  them  with  the  cerebrospinal  system,  and  postganglionic 
fibers  which  go  to  supply  the  viscera,  as  already  mentioned. 

The  cerebrospinal  nervous  system,  on  the  other  hand,  is  con- 
trolled by  the  will.  Its  action  is  quick  and  definite.  There  are 
no  ganglia  interposed  along  the  path  of  the  nerve  to  modify  the 
impulses  which  originate  in  the  brain,  but  they  are  carried  directly 
from  cell  bodies  in  the  brain  and  cord  to  the  muscles  involved; 
and  immediate  action  results. 

The  vegetative  system  consists  of  three  divisions,  the  cranial, 
the  thoracico-lumbar  or  sympathetic,  and  the  sacral,  as  shown 
in  Fig.  24  taken  from  Cannon.  No  connecting  neurons  for  the 
vegetative  system  are  given  off  from  those  portions  of  the  cord 
which  send  out  nerves  to  the  fore  and  hind  limbs. 

The  cranial  fibers  pass  for  the  most  part  within  the  trunk  of 
the  nervus  oculomotorius  (third  cranial)  without  interruption,  to 
the  ciliary  ganglion,  whence  they  furnish  constrictor  impulses 
to  the  sphincter  of  the  iris.    They  also  supply  the  ciliary  muscle. 

The  bulbar  portion  passes  through  the  nervus  facialis  (seventh 
cranial)  and  nervus  glossopliaryngeus  (ninth  cranial)  to  the  sali- 
vary glands,  tongue,  and  blood  vessels  of  the  head.  Stimrlation 
causes  increased  salivary  flow  and  dilatation  of  the  vessels  of  the 
head.    Degeneration  causes  tongue  to  protrude  to  side  of  lesion. 

The  most  important  branch  of  the  vegetative  system  coming 
from  the  cranial  portion  of  the  cord  is  the  nervus  vagus  which  is 
the  chief  source  of  nerve  supply  for  the  internal  viscera.  It  sup- 
plies the  heart,  bronchial  tree,  esophagus,  stomach,  intestines, 
pancreas  and  liver. 

The  sacral  branch  is  the  nervus  pelvicus.  It  innervates  the 
descending  colon,  sigmoid,  anus,  bladder,  and  generative  organs. 
The  sympathetic  fibers  pass  from  the  ganglia  which  lie  near  the 


CAUSE   OP  VARIABILITY   OF   SYMPTOMS  187 

vertebral  column  in  the  thoracic  and  upper  lumbar  regions. 
Each  ganglion  has  its  connector  fiber  which  joins  it  with  its  re- 
spective segment  of  the  cord.  The  sympathetic  cells  have  passed 
out  from  the  central  nervous  system  and  form  the  ganglionated 
cord  and  from  this  fibers  are  widely  distributed  throughout  the 
body. 

Antagonistic  Action  of  Greater  Vagus  and  Sympathetic  Fibers 
Shown  in  Variability  of  Symptoms. — Many  structures  are  in- 
nervated by  both  the  greater  vagus  and  sympathetic  systems,  and 
wherever  this  double  innervation  is  found,  the  action  of  the  two  is 
antagonistic ;  as  in  the  eye,  where  the  vagus  contracts  the  pupil,  the 
sympathetic  dilates  it ;  or  in  the  heart,  where  the  vagus  slows,  the 
sympathetic  accelerates.  It  is  fairly  definitely  settled  that  all 
so-called  vegetative  organs  of  the  body,  with  the  exception  of 
the  sweat  glands,  pilomotor  muscles  and  vascular  muscles  of  the 
viscera  are  supplied  by  fibers  from  both  the  sympathetic  and 
vagus  systems.  These  latter  structures  are  supplied  by  the  symp- 
athetic alone. 

The  table  from  Eppinger  and  Hess19  (page  188)  shows  this  an- 
tagonism in  the  principal  structures  concerned  in  our  study. 

From  it  one  can  readily  understand  that  the  normal  healthy 
state  in  the  vegetative  organs  is  produced  and  maintained  by 
the  sum  total  of  sympathetic  stimulation,  equaling  the  sum 
total  of  vagus  stimulation.  If  either  the  one  or  the  other  over- 
balances, equilibrium  is  disturbed   and  dysfunction  results. 

Both  the  greater  vagus  and  the  sympathetic  divisions  of  the 
vegetative  systems  are  influenced  by  a  great  number  of  natural 
as  well  as  many  pathological  conditions. 

These  systems  are  influenced,  in  fact,  regulated  to  a  certain 
extent,  during  the  state  of  health,  by  the  secretions  from  the 
various  internal  glands.  Each  gland  produces  substances 
which  contribute  ,to  the  regulation  of  other  glands  and  struc- 
tures. These  are  called  internal  secretions.  They  are  cast  into 
the  blood  stream  when  formed  and,  circulating  throughout  the 
body,  choose  with  precision  the  structure  which  they  are  to 
influence.     One  will   act  wholly    on    the    sympathetic    nerves 

"Vagotonia — A  Clinical  Study  in  Vegetative  Neurology,  Nervous  and  Mental  Diseases 
Publishing  Company,  New  York,  1915. 


188 


NERVOUS   SYSTEM  IN   TUBERCULOSIS 


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SYMPTOMS   OF   SYMPATHETIC   STIMULATION  189 

(adrenin),  another  on  the  vagus  (supposedly  the  secretion  from 
the  pancreas),  and  others  will  act  only  on  some  particular 
branch  of  one  or  the  other  system. 

Pathologically,  toxemia  produces  a  picture  of  central  cell 
stimulation,  but  a  peripheral  expression  of  general  discharge 
through  the  sympathetic  system.  In  inflammations  of  the  in- 
ternal viscera,  whatever  irritation  is  present  probably,  as  mentioned 
later,  influences  both  vagus  and  sympathetic  filaments  peripherally 
and  causes  them  to  stimulate  structures  reflexly. 

It  is  interesting  to  note  that  toxemia,  and  the  depressive 
emotional  states  such  as  fear,  anxiety,  discouragement,  worry, 
and  disappointment,  are  accompanied  by  the  same  symptom- 
complex.  This  is  particularly  easy  to  recognize  in  tubercu- 
losis, because  it  is  a  disease  which  manifests  so  many  periods 
of  slight  activity  accompanied  by  a  low  or  moderate  degree  of 
toxemia,  which  disappears  after  a  few  days'  duration;  and,  be- 
cause it  is  likewise  accompanied  by  so  many  of  the  depressive 
emotional  states,  which  come  and  go  as  the  causes  which  pro- 
duce them  come  and  go. 

The  symptoms  of  toxemia  and  of  the  depressive  emotional 
states  are:  headache,  malaise,  nervous  irritability,  insomnia, 
lack  of  appetite,  coated  tongue,  inhibition  of  gastric  and  in- 
testinal secretion  and  motility,  constipation,  fever,  pallor,  and, 
at  times,  sweating. 

The  above  symptoms  are  not  constantly  present,  nor  do  they 
manifest  themselves  in  equal  degree  in  each  organ  innervated 
by  the  sympathetic  system.  They  are  sufficiently  constant, 
however,  to  indicate  that  they  are  a  result  of  a  central  stimu- 
lation of  the  sympathetic  system. 

The  variability  of  the  symptoms  caused  by  central  stimula- 
tion of  the  sympathetics  in  pulmonary  tuberculosis  is  due  to 
the  fact  that  peripheral  reflex  stimulation  of  the  pulmonary 
nerve  endings  of  both  the  vagus  and  sympathetic  is  also  pres- 
ent whenever  activity  in  the  pathological  process  is  sufficiently 
acute  to  produce  toxemia.  It  is  possible;  in  fact,  I  have  often 
observed  that  the  reflex  peripheral  stimulation  of  the  vagus 
was  sufficiently  strong  to  overcome  both  central  and  peripheral 
stimulation  of  the  sympathetic.     This  I  have  seen  manifested 


190  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

in  one  or  more  of  the  following  ways:  a  moist  clean  tongue,  a 
hyperacidity,  or  a  relatively  slow  pulse,  during  periods  of  acute 
toxemia  accompanying  cavity  formation  in  the  lung. 

After  the  acute  activity  passes  over,  unless  the  patient  is 
prolonging  the  toxemia  by  wrong  methods  of  living,  particularly 
overexertion;  or  is  suffering  from  such  depressive  influences 
as  worry,  fear,  and  discouragement,  the  central  stimulation  of 
the  sympathetics  ceases  and  whatever  symptoms,  arising  from 
the  nervous  system,  remain,  are  due  to  the  irritation  of  the 
nerve  endings  by  the  inflammation  in  the  lung,  and  are  ex- 
pressed as  reflex  phenomena  in  other  viscera. 

There  is  no  question  that  peripheral  stimulation  of  the 
greater  vagus,  in  one  of  its  branches,  will  result  in  stimulation 
and  the  production  of  vagus  effect  in  the  other  branches  of  the 
greater  vagus.  Stimulation  in  the  intestine  causes  slowing  of 
the  heart;  stimulation  in  the  uterus,  ovary,  or  testicle  causes 
vomiting;  and,  stimulation  of  the  vagus  in  the  nasal  mucous 
membrane  will   cause   bronchial  spasm   or    asthma. 

Whether  the  same  is  true  of  the  sympathetics  is  open  to  ques- 
tion. Sensory  paths  in  the  sympathetics  are  supposed  to  take 
the  same  course  as  in  the  spinal  nerves.  The  nerve  cells  for  them 
lie  in  the  posterior  root  ganglia  of  the  cord;  and  the  path  is  sup- 
posed to  be  uninterrupted  by  ganglia.  Thus,  Gaskell20  says: 
"All  the  afferent  fibers  have  their  nutrient  centers  in  the  posterior 
root  ganglia.  No  peculiarity,  therefore,  exists  on  the  afferent 
side;  the  course  of  the  sensory  fibers  is  the  same  in  all  sensory 
nerves,  viz. :  direct  to  the  cells  of  the  posterior  root  ganglia,  with 
no  connection  with  any  cells  in  sympathetic  ganglia." 

If  this  is  true,  then  we  are  wrong  in  supposing  that  peripheral 
irritation  of  the  sympathetic  fibers  in  one  viscus  can  cause  reflex 
action  in  some  other  viscus  except  the  impulse  be  carried  to  the 
cord,  there  to  be  transferred  from  the  posterior  root  ganglion  to 
the  anterior  root  and  through  the  connector  fibers  to  the  motor 
cells  in  the  sympathetic  ganglia  of  the  same  segment,  whence  it  is 
transmitted  to  the  viscus.  Beehterew21  says:  "The  functions 
of  the  sympathetic  nervous  system  are  divided,  as  is  well 
known,    into    sensory,    motor,    secretory,    and    trophic.      The 


20The  Involuntary  Nervous  System,  Longmans,  Green  &  Co.,  New  York,  1916,  p.   17. 
21Die  Functionen  der  Nervencentra,  Gustav  Fischer,  Jena,   1908,  pp.   59-60. 


SYMPATHETICS  AND  VISCERAL  REFLEXES  191 

sensory  sympathetic  fibers  transmit  impressions  to  the  spinal  cord 
and  brain ;  the  motor  supply  the  involuntary  or  unstriped  muscu- 
lature. Aside  from  this,  there  are  mixed  fibers  which  establish 
a  connection  between  neighboring  sympathetic  ganglia.  The 
tonus  of  unstriped  muscle  fibers  is  reflexly  maintained  through 
sympathetic  ganglia.  The  sympathetic  system  is  also,  without 
doubt,  operative  in  originating  many  reflexes  in  the  sphere  of  the 
internal  organs. 

"There  is  lacking  today  scarcely  a  single  proof  of  the  fact  that 
cellular  interruption  of  nerve  fibers  takes  place  in  the  sympathetic 
ganglia.  With  this  fact  established  these  ganglia  assume  at  once 
the  role  of  true  nerve  centers.  It  follows  as  a  consequence  from 
the  proof  of  interruption  as  produced  by  Eamon  Y.  Cajal  that  the 
nature  and  manner  of  the  relationship  between  nerve  fibers  and 
nerve  cells  in  the  sphere  of  the  sympathetic  system  is  in  reality 
the  same  as  in  the  spinal  and  cerebral  portions  of  the  central 
nervous  system." 

It  seems  to  me  that  we  are  obliged  to  assume  the  truth  of  this 
position  with  reference  to  the  reflex  relationship  of  the  internal 
viscera  through  the  sympathetics.  It  is  the  only  way  that  we  can 
account  satisfactorily  for  the  symptomatology  of  disease  of  the 
internal  viscera. 

If  this  is  not  true,  then  we  must  consider  that  the  only  way  in 
which  an  inflammatory  process  in  one  viscus  can  influence  another 
viscus  through  the  sympathetics  is  by  producing  substances  which 
gain  entrance  to  the  circulation  and  cause  central  stimulation  of 
sympathetic  cells  as  in  case  of  the  various  toxemias,  or  peripheral 
stimulation  as  in  the  case  of  adrenin.  It  precludes  the  possibility 
of  such  definite  reflexes  affecting  internal  viscera  as  those  that 
we  encounter  in  the  branches  of  the  greater  vagus. 

In  my  discussion  of  the  reflex  symptoms  found  in  tubercu- 
losis and  the  antagonistic  action  manifested  between  the  great- 
er vagus  and  sympathetic  in  their  production,  it  will  be  neces- 
sary for  the  reader  to  bear  in  mind  that  there  is  this  doubt  as  to 
whether  the  sympathetics  are  able  to  produce  a  true  reflex, 
which  shows  in  other  viscera  without  mediation  in  the  spinal 
cord.    There  is  no  doubt  however,  as  to  the  influences  which  are 


192  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

present,  stimulating  the  sympathetics  now  centrally,  now  periph- 
erally, and  increasing  the  general  sympathetic  tonus.  This 
at  times  overcomes  the  vagus  tonus,  and  at  other  times  is  over- 
come by  the  greater  vagus.  In  my  previous  papers  I  followed 
the  assumption  that  peripheral  stimulation  of  the  sympathetics 
causes  reflex  action  in  other  viscera;  but,  while  clinical  facts 
seem  to  warrant  this,  it  is  best  to  consider  it  as  still  subject  to 
doubt. 

In  pulmonary  tuberculosis  after  all  conditions  which  ef- 
fect general  central  or  peripheral  stimulation  of  the  sym- 
pathetics seem  to  have  been  removed  sometimes  the  tonus 
is  greater  in  the  vagus  system,  at  other  times  in  the  sympa- 
thetic. As  a  rule,  however,  except  during  periods  of  increased 
toxemia,  which  I  shall  discuss  later,  my  observation  leads  me 
to  believe  that  the  vagus  tonus  is  greater  than  the  sympathetic 
tonus  in  early  tuberculosis.  This  is  shown  on  the  part  of  the 
heart,  and  particularly  on  the  part  of  the  gastrointestinal  tract. 
There  are  many  exceptions  to  this,  however,  especially  among 
those  congenitally  weak  and  those,  in  whom  sympathetic  tonus 
predominates  naturally. 

In  estimating  the  relative  tonus  of  the  vagus  and  sympathetic 
systems  it  is  necessary  to  bear  in  mind  that  increased  tonus 
might  show  in  one  division  of  the  nerves  and  not  in  all,  and 
that  this  increased  tonus  in  particular  divisions  might  not  be 
constant.  This  variability  is  due  to  the  fact  that  there  are 
many  factors  acting  at  the  same  time  which  cause  stimulation 
and  that  some  of  these  have  selective  action  for  certain  struc- 
tures. This  is  not  only  evident  in  the  reflexes  but  also  in  the 
internal  secretions  which  affect  the  two  systems.  It  is  also 
evident  from  the  fact  that  the  tuberculous  patient  may  have 
increased  or  decreased  tonus  in  either  the  vagus  or  sympathetic 
system  from  causes  other  than  those  which  operate  as  a  result 
of  the  pulmonary  infection. 

Because  of  the  antagonistic  action  of  the  vagus  and  sympa- 
thetic systems  the  function  of  many  organs  is  rendered  unstable 
when  an  unequal  stimulation  of  one  or  the  other  occurs.  The 
heart,  while  at  rest,  is  often  slower  than  normal,  but  on  exer- 
tion,  or  during  periods  of  toxemia  or  depression  at  once  be- 


ALTERNATING   VAGUS   AND   SYMPATHETIC    TONUS  193 

comes  more  rapid  than  normal  and  settles  down  to  the  normal 
much  slower  than  it  should.  The  appetite,  while  disturbed  dur- 
ing conditions  which  favor  increased  absorption  of  toxins  such 
as  exertion,  or  during  periods  of  increased  activity  in  the  tu- 
berculous foci,  or  during  periods  of  depression  and  worry,  is 
often  normal  and  even  above  normal  when  the  patient  is  put  at 
rest  in  the  open  air  under  favorable  circumstances  which  offer 
him  hope  of  cure.  The  same  is  true  of  the  gastric  and  intestinal 
functions.  Hyperacidity  and  hypermotility  are  the  rule  in 
early  tuberculosis,  when  toxemia  is  relieved.  The  intestinal  tract 
also  shows  the  same  increased  tonus.  The  vagus  system,  the  one 
which  if  slightly  in  the  ascendency,  conserves  the  healthful  action 
of  the  important  internal  organs,  overcomes  its  antagonist  in 
early  tuberculosis  for  the  most  of  the  time  and  this  offers  the 
patient  an  increased  opportunity  for  restoration  to  health.  If 
vagus  tonus  is  marked,  however,  it  proves  harmful. 

During  waves  of  increased  activity  in  the  tuberculous  focus, 
however,  and  during  the  period  when  the  patient  is  causing  in- 
creased absorption  of  toxins  by  overexertion  and  other  faulty 
habits,  likewise  during  periods  of  great  depression  from  other 
causes,  the  excessive  stimulation  of  the  sympathetic  produced  by 
both  reflex  action  and  emotional  states  overcomes  the  increased 
vagus  tonus  and  causes  symptoms  which  are  characteristic  of 
sympathetic  irritation,  such  as  sweating,  rapid  heart,  decreased 
appetite,  hypochlorhydria,  deficient  gastric  motility,  and  altera- 
tion in  the  secretion  and  motility  of  the  entire  intestinal  tract. 

Aside  from  the  antagonistic  action  of  these  two  systems  it 
seems  probable  that  antagonistic  fibers  are  at  times  supplied  to 
organs  by  the  same  system. 

In  health  a  state  of  equilibrium  is  maintained  in  the  various 
organs  as  a  result  of  the  antagonistic  action  of  these  two  systems. 
In  any  disease  which  affects  either  by  stimulation  or  by  setting 
aside  the  normal  nerve  tonus  of  any  important  branch  or  group 
of  fibers  of  either  or  both  of  these  systems,  there  is  a  conse- 
quent disturbance  of  equilibrium  which  results  in  a  pathologi- 
cal state. 

This  is  evident  in  the  production  of  nausea  through  eye  strain, 
or  the  slowing  of  the  heart  in  abdominal  lesions  which  affect  the 


194  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

depressor  fibers  of  the  vagus.  So  it  is  evident  in  pulmonary 
inflammation. 

Effect  of  Internal  Secretions  on  Symptomatology. — Aside  from 
the  direct  stimulation  of  the  nerves  by  inflammatory  processes 
we  must  recognize  the  influence  of  substances  of  a  chemical 
nature  which  act  either  upon  terminal  filaments  or  nerve  centers. 
Thus  the  primary  action  of  toxins  is  upon  the  central  cell  bodies. 
A  secondary  action  may  be  a  totally  different  one  and  depend 
on  certain  secretions  which  are  set  free  as  a  result  of  the  pri- 
mary toxic  influence,  such  as  occurs  when  adrenin  is  set  free 
by  certain  emotional  states  or  gastric  secretion  is  stimulated 
by  the  smell  or  taste  of  savory  food.  No  doubt  future  study 
will  clarify  this  subject  very  much  by  the  discovery  of  the  true 
relationship  which  exists  between  many  of  the  internal  secre- 
tions and  the  structures  controlled  by  them. 

Internal  Secretion  of  the  Thyroid. — At  this  point  of  our  dis- 
cussion it  might  be  well  to  call  attention  to  the  enlargement  of 
the  thyroid  gland,  which  occurs  commonly  during  early  clinical 
tuberculosis.  I  realize  that  the  tendency  of  scientific  opinion 
of  today  is  toward  the  theories  of  insufficient  iodine  being  ob- 
tained by  the  individual  and  that  of  infections  being  the  causa- 
tive factors  in  enlargements  of  the  thyroid  gland.  I  cannot 
help  believing,  from  my  own  experience,  however,  that  a  hyper- 
plasia of  the  thyroid  gland  takes  place  in  the  presence  of 
toxemia,  where  no  infection  of  the  gland  itself  occurs.  This 
can  be  rationally  explained,  now  that  we  have  the  works  of 
physiologists  (Cannon),  which  show  that  sympathetic  stimulation 
increases  thyroid  secretion.  When  toxemia  is  present,  as  I  have 
discussed  fully  throughout  this  monograph,  there  is  a  general 
sympathetic  stimulation.  One  of  the  results  of  sympathetic  stimu- 
lation is  increased  action  of  the  adrenal  gland.  If  adrenin 
stimulates  the  thyroid,  it  is  but  natural  to  suppose  that  increased 
adrenin  calls  for  increased  flow  of  thyroid  secretion.  It  is  a 
principle  in  physiology  that  increased  function,  not  only  of 
muscles,  but  ,of  secreting  organs,  is  accompanied  by  increased 
blood  to  the  part,  and  increase  in  the  size  of  the  cellular  com- 
ponents; consequently,  it  is  not  at  all  beyond  reason  to  suppose 
that  these  enlargements  of  the  thyroid  gland,    which    occur   in 


OVARIAN  SECRETION  195 

early  clinical  tuberculosis,  and  which  are  also  noted  when  we 
have  infections  in  other  parts  of  the  body,  such  as  the  tonsil  and 
nasal  sinuses,  might  be  due  to  a  hyperplasia  of  the  gland,  re- 
sulting from  increased  stimulation.  That  this  explanation  is 
plausible  is  further  implied  in  the  fact  that  the  gland  returns  to 
normal  after  the  toxemia  disappears. 

Internal  Secretion  of  the  Ovary. — It  is  also  well  to  bear  in 
mind  the  influence  of  the  internal  secretion  of  the  ovary  in  the 
production  of  the  premenstrual  rise  in  temperature.  I  have  sug- 
gested, as  an  explanation  of  this  phenomenon,  that  it  represents 
a  stimulation  of  the  vasomotor  center  which  acting  through  the 
sympathetic  system,  causes  vasoconstriction  and  interference  with 
the  dissipation  of  heat  (see  Chapter  XXX).  The  nervous  phenom- 
ena which  occur  at  the  menopause  when  the  ovarian  secretion 
ceases  are  undoubtedly  largely  those  of  disturbed  nerve  balance 
and  particularly  that  of  increased  vagus  tonus ;  and  further  indi- 
cate that  the  internal  secretion  of  the  ovary  acts  by  stimulating 
the  sympathetic  nervous  system.  The  premenstrual  nervous  dis- 
turbances which  so  commonly  complicate  our  symptom-complex 
in  tuberculosis  become  more  intelligible  with  the  understanding  of 
their  causation. 

Symptoms  Appearing  at  the  Menopause  Due  to  the  Cessation 
of  Ovarian  Secretion. — The  menopause  is  usually  considered  as  a 
critical  period  in  woman's  life.  It  is  a  time  when  the  normal 
resistance  seems  lessened,  therefore  it  is  of  great  interest  to  the 
students  of  tuberculosis.  It  has  long  been  known  that  at  that  time 
a  general  atrophy  of  the  female  generative  organs  takes  place; 
but  the  manner  in  which  this  acts  to  produce  the  symptoms  noted 
has  not  been  thoroughly  understood. 

At  this  time  instability  of  the  nervous  system  is  the  most  prom- 
inent symptom.  With  more  accurate  clinical  observation  and  our 
increasing  knowledge  of  the  action  of  the  glands  of  internal  se- 
cretion, this  condition  becomes  more  understandable.  As  puberty 
comes  on,  ushering  in  the  child-bearing  period,  very  marked 
changes  take  place  in  both  the  physical  and  nervous  make-up  of 
the  individual.  In  this  new  period  of  woman's  life  there  is  one 
particular  new  force  added  to  those  which  have  been  previously 
operative;  namely,  the  internal  secretion  produced  by  the  sex 


196  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

glands,  particularly  the  ovary.  The  ovarian  secretion  acts  upon 
the  sympathetic  nervous  system  and  stimulates  all  structures 
supplied  by  it.  Consequently  there  is  a  stimulation  of  certain 
other  glands  of  internal  secretion, — such  as  the  adrenal  gland, 
stimulation  of  which  causes  increased  oxidation;  and  the  thyroid 
gland,  stimulation  of  which  causes  increased  metabolical  activity. 
The  action  upon  these  two  glands  of  internal  secretion  is  most 
evident,  clinically,  but  doubtless  the  influence  of  this  secretion  is 
felt  generally;  because  we  cannot  conceive  of  any  new  potent 
force  coming  into  the  chain  of  internal  secretions  without  dis- 
turbing the  established  equilibrium  in  all. 

The  disturbance  of  this  equilibrium  is  not  continuous  during 
the  child-bearing  period,  but  is  most  marked  during  the  period  of 
ovulation.  This  causes  the  cycle  in  woman's  life  which  has  been 
clinically  observed  throughout  the  child-bearing  period.  It  would 
seem  that  the  ovarian  secretion  is  given  into  the  blood  stream  ir- 
regularly even  in  the  same  individual  and  that  its  influence  upon 
the  system  is  much  greater  in  certain  individuals  than  in  others. 

In  observing  many  cases  of  pulmonary  tuberculosis  over  pro- 
longed periods  of  time,  I  have  noticed  the  influence  of  this  secre- 
tion as  it  expresses  itself  in  the  nervous  system.  The  manner  in 
which  it  influences  the  pulse  and  temperature  is  shown  in  clinical 
charts  which  are  given  throughout  these  pages,  and  may  be 
particularly  studied  in  patients  whose  temperature  and  pulse 
curves  are  shown  over  a  long  period  of  time  in  "The  Tubercu- 
losis Clinic,"  Chapter  L,  Vol.  II. 

It  will  be  noticed  that  in  some  patients  this  influence  shows 
with  almost  absolute  regularity  month  after  month.  It  may  be 
possible  that  the  internal  secretion  of  the  ovary  is  given  off  con- 
tinuously; but  it  is  given  off  in  greater  quantities  in  most  in- 
dividuals during  the  two  weeks  preceding  menstruation.  At 
times  its  influence  is  seen  on  the  14th  day  following  menstruation 
and  shows  as  a  slight  rise  in  temperature,  which  continues  until 
the  day  of  menstruation  when  it  drops  again.  Sometimes  the 
pulse  will  also  show  an  acceleration.  In  others  this  may  not  be 
noticeable.  My  observation  has  been  that  acceleration  of  the 
pulse  is  not  as  general  as  the  elevation  of  temperature,  but  that 
it  occurs  most  commonly  when  marked  nerve  irritability  is  pres- 


MENSTRUAL    CYCLE   AND    MENOPAUSE  197 

ent.  Menstruation  is  also  preceded  by  a  rise  in  blood  pressure, 
and  accompanied  by  a  fall  in  pressure. 

When  marked  nerve  stimulation  is  present,  it  manifests  itself 
in  such  symptoms  as  insomnia,  depression,  disturbed  appetite  and 
increased  irritability.  These  symptoms  are  more  marked  as  a 
rule  only  a  day  or  two  preceding  menstruation.  According  to  my 
observation,  this  pre-menstrual  rise  in  temperature  may  come  on 
any  time  from  the  14th  day  prior,  up  to  the  day  of  menstruation  it- 
self. In  a  few  instances  it  would  seem  that  the  ovarian  secre- 
tion does  not  affect  the  patient  prior  to  menstruation  but  only  dur- 
ing the  same  and  probably  for  a  few  days  following.  In  these 
cases  there  seems  to  be  a  reverse  curve.  This  will  be  noticed  in 
some  of  the  charts  in  these  pages  (see  Fig.  128,  Vol.  II)  ;  but  this 
is  infrequent.  We  assume  that  the  stimulation  of  the  sympathetic 
is  coincident  with  ovulation,  and  are  fortified  in  this  assumption 
by  the  fact  that  all  symptoms  of  sympathetic  stimulation  disap- 
pear when  the  menopause  has  been  passed. 

During  the  child-bearing  period  the  organism  gradually  ac- 
customs itself  to  the  ovarian  secretion  and  its  stimulating  effect 
upon  the  nervous  system.  The  effect  of  any  sympathetic  stimula- 
tion if  counterbalanced  at  all,  is  counterbalanced  through  stimula- 
tion of  the  vagus.  It  is  probable  that  in  many  individuals  the 
ovarian  secretion  is  so  slight  in  its  influence  that  its  action  is 
within  the  bounds  of  sympathetic  and  vagus  balance;  but  where 
the  nervous  stability  is  threatened  by  the  influence  of  the  ovarian 
secretion,  equilibrium  may  be  maintained  by  some  natural  physio- 
logical force  which  is  able  to  counteract  the  sympathetic  influence. 

When  the  necessity  for  further  ovulation  ceases,  the  ovarian 
secretion  also  ceases.  The  result  is  a  marked  unbalancing  in  the 
nervous  system.  The  picture  on  the  part  of  the  vegetative  system 
is  that  of  marked  instability,  the  vagus  influences,  for  the  time, 
being  in  the  ascendency.  Not  only  the  vegetative  nervous  sys- 
tem but  the  central  nervous  system  and  psychical  control  are  often 
disturbed.  So  this  is  a  period  when  woman  is  required  to  ad- 
just herself  to  new  conditions. 

Our  conception  of  the  etiology  of  symptoms  which  accompany 
the  menopause,  are: 

1.  A  withdrawal  of  the  ovarian  secretion  from  circulation. 


198  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

2.  The  elimination  of  the  normal  stimulation  of  the  sympa- 
thetics  produced  by  the  ovarian  secretion,  which  results  in  a  dis- 
turbance of  balance  in  the  vegetative  nervous  system,  permitting 
vagus  tonus  for  the  time  being  to  be  in  the  ascendency. 

3.  A  disturbance  on  the  part  of  the  higher  nerve  centers  as 
a  result  of  the  general  disturbance  in  the  vegetative  system;  and 
possibly  also  directly  as  a  result  of  the  absence  of  the  action  of 
the  ovarian  secretion  on  the  higher  centers. 

4.  A  general  psychical  instability  resulting  from  the  height- 
ened irritability  of  the  vegetative  system  and  the  higher  nerve 
centers. . 

ANTAGONISTIC  ACTION  OP  GREATER  VAGUS  AND 

SYMPATHETIC  AS  SHOWN  IN  SYMPTOMS  OF 

PULMONARY  TUBERCULOSIS. 

Let  us  now  proceed  to  apply  the  principles  involved  in  the 
stimulation  of  the  nerves  of  the  vegetative  system  to  pulmonary 
tuberculosis  and  the  explanation  of  such  phenomena  as  are  caused 
by  the  disturbed  balance  in  the  vagus  and  sympathetic  systems. 

In  tuberculosis  we  must  conceive  of  a  condition  in  which  both 
the  vagus  and  sympathetic  systems  are  simultaneously  stimu- 
lated, but  one  in  which  either  one  or  the  other  usually  yields  with 
a  resultant  disturbed  equilibrium. 

Dilated  Pupil. — At  least  50  per  cent  of  tuberculous  patients 
show  a  dilated  pupil  on  the  side  of  the  involvement  during  some 
time  when  the  inflammation  is  acute;  and  it  is  probable  that  a 
much  larger  per  cent  would  show  it  if  observation  could  be 
made  continuously.  This  indicates  that  the  action  of  the  sym- 
pathetics  overcomes  that  of  the  vagus.  This  dilator  effect  is 
due  to  irritation  of  the  fibers  from  the  first  and  second  thoracic 
segments  of  the  cord.  Artificial  stimulation  of  these  fibers  causes 
the  same  dilator  effect.  Aside  from  the  disturbances  in  the  pupil 
the  ciliary  body  is  stimulated  to  contractions  by  irritation  of 
the  vagus.  I  am  inclined  to  believe  that  there  is  often  a  serious 
disturbance  of  accommodation  in  tuberculous  patients  due  to  the 
unequal  stimulation  of  the  pulmonary  ends  of  the  vagus  and 
sympathetic.     It  is  surprising  to  see  how  many  patients  com- 


VEGETATIVE   SYSTEM   AND   SYMPTOMATOLOGY  199 

plain  of  headache  if  they  continue  to  use  their  eyes  for  reading, 
knitting,  or  sewing,  as  they  have  been  accustomed  to  do  prior 
to  their  illness.  They  also  seem  to  show  an  increased  sensitive- 
ness to  bright  light  and  I  often  find  it  necessary  to  suggest  that 
the  bed  be  so  placed  that  the  light  will  not  shine  directly  in  the 
eyes.  Change  of  eye  glasses  is  made  necessary  more  often  than 
prior  to  illness  even  in  early  and  chronic  cases  which  are  only 
slightly  active. 

Hectic  Flush. — The  exact  explanation  of  hectic  flush  is  some- 
what vague.  Why  there  should  be  a  dilation  of  the  vessels  of 
the  face  and  ear  when  the  sympathetics  supplying  them  con- 
tain both  dilator  and  constrictor  fibers,  as  determined  by  arti- 
ficial stimulation,  can  be  answered  only  by  assuming  that  the 
natural  stimulant  in  tuberculosis  has  a  peculiar  affinity  for  the 
dilators;  or,  that  it  paralyzes  the  constrictors.  The  constrictor 
tone  of  the  vessels  of  the  mouth,  cheek,  ear  and  head  is  main- 
tained through  the  superior  cervical  ganglion  by  fibers  which  re- 
ceive their  stimulation  from  the  connector  nerves  arising  from 
the  first,  second,  third,  fourth  and  fifth  thoracic  segments 
(maximum  effect  coming  from  second,  third  and  fourth),  and 
in  the  case  of  the  ear,  the  third  cervical. 

The  dilator  effect  seems  to  be  due  to  either  an  affinity  for 
the  dilators  or  an  overstimulation  of  the  constrictors  resulting 
in  their  exhaustion.  A  clinical  observation,  which  seems  to 
corroborate  the  latter  supposition,  is  that  hectic  flush  does  not 
appear  early  in  tuberculosis.  It  nearly  always  appears  coinci- 
dent with  marked  clinical  activity;  so,  it  would  seem  that  there 
exists  not  only  a  stimulation  of  fibers  somewhere  in  their  course, 
but  also  a  central  stimulation  produced  by  the  toxins  in  order 
to  overcome  the  constrictor  and  produce  the  dilator  effect. 

Heart. — In  the  heart  in  tuberculosis  we  have  so  many  condi- 
tions present  which  influence  the  pulse  rate  that  it  is  impossible 
to  accurately  ascribe  to  the  vagus  and  sympathetic  systems  the 
part  which  each  plays.  Impulses  are  carried  through  both  sys- 
tems, because  both  are  constantly  irritated. 

As  a  result  of  this  double  source  of  impulses,  the  one  through 
the  vagus  tending  to  slow  the  heart,  the  other  through  the  sym- 
pathetic, attempting  to  quicken  its  action,  there  is  a  marked 


200 


NERVOUS   SYSTEM   IN   TUBERCULOSIS 


5  2 


VARIABILITY  OF  HEART  BEAT  201 

disturbance  of  equilibrium.  This  shows  early  in  the  disease  be- 
fore such  conditions  as  loss  of  pulmonary  tissue,  heart  strain,  and 
degenerative  changes  can  be  considered.  The  heart  beat  may 
be  normal,  slower  than  normal,  or  only  slightly  faster  than  nor- 
mal while  the  patient  is  at  rest ;  but  it  is  often  unduly  rapid  on 
exertion,  and  returns  to  normal  slower  than  in  the  healthy 
individual. 

This  relative  slowness  of  the  heart  beat  is  often  noticed  during 
periods  of  temperature,  as  compared  with  the  same  degree  of 
temperature  in  other  diseases.  This  is  unquestionably  the  result 
of  an  inhibitory  reflex  through  the  vagus,  the  impulse  coming 
from  the  irritation  in  the  lung.  When  the  intestinal  tract  is  af- 
fected with  tuberculosis,  then  another  division  of  the  greater 
vagus  system  is  stimulated  and  we  often  see  this  inhibitory  ac- 
tion accentuated,  with  still  greater  departure  in  pulse  rate  from 
that  which  would  be  expected  with  the  degree  of  temperature 
present.  If  an  unusual  slowing  of  the  pulse  occurs  in  the  course 
of  pulmonary  tuberculosis,  coincident  with  an  elevation  of  one 
or  two  degrees  in  the  temperature  curve,  reflex  vagus  irrita- 
tion should  be  considered  as  a  probable  cause  and  a  complicat- 
ing intestinal  tuberculosis  be  suspected. 

These  vagus  influences  are  seen  very  often  clinically,  as  shown 
in  the  following  charts: 

Fig.  29  is  the  chart  of  a  patient  suffering  from  moderately  ad- 
vanced tuberculosis,  but  in  whom  toxemia  was  a  very  small 
factor.  It  will  be  noted  that  the  temperature  which  was  between 
99°  and  100°,  on  entering  the  institution  dropped  to  practically 
normal  after  10  days'  rest.  The  pulse  was  found,  as  a  rule,  be- 
tween 60  and  70.  This  patient's  resisting  power  was  good  and 
his  chances  of  recovery  splendid,  in  spite  of  a  widespread  lesion. 
This  patient  was  markedly  vagotonic. 

Fig.  30  shows  the  pulse  of  a  patient  suffering  from  very  exten- 
sive inflammation  of  the  right  lung,  which  went  on  to  the  rapid 
formation  of  fibrosis,  and  eventually  resulted  in  arrestment. 
This  case  is  described  in  Volume  II,  Chapter  L,  Case  2,514. 
It  will  be  noticed  that  while  the  temperature  was  ranging  above 
102°  the  pulse  was  not  exceeding  100  beats  per  minute.  Toward 
the  end  of  the  month  a  very  interesting  condition  presented  it- 


202 


NERVOUS  SYSTEM  IN  TUBERCULOSIS 


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VAGUS  TONUS  AS  SHOWN  IN  PULSE 


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NERVOUS  SYSTEM  IN  TUBERCULOSIS 


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206  NERVOUS.  SYSTEM  IN  TUBERCULOSIS 

self, — the  temperature  dropped  and  the  pulse  increased  in  fre- 
quency. This  may  be  explained  on  the  ground  that  as  the  in- 
flammation in  the  lung  lessened,  toxemia  decreased  and  the  tem- 
perature dropped ;  the  reduced  inflammation  lessened  the  amount 
of  irritation  of  the  pulmonary  vagus  and  permitted  the  antago- 
nistic action  of  the  sympathetic  to  increase  the  pulse  rate.  The 
patient  was  in  bed  not  even  sitting  up  to  eat  during  the  entire 
month. 

Fig.  31  shows  the  temperature  curve  of  a  patient  suffering  from 
acute  caseous  pneumonic  phthisis.  It  will  be  noticed  that  the 
disproportion  between  the  temperature  and  pulse  was  very 
marked.  While  the  temperature  ranged  from  a  maximum  of 
100°  and  102°,  the  pulse  remained  between  70  and  80.  This  pa- 
tient eventually  died  of  miliary  tuberculosis,  with  meningeal 
complication,  although  there  was  no  clinical  evidence  of  either 
intestinal  or  meningeal  infection  present  to  cause  the  slowing 
of  the  pulse  at  the  time  represented  by  the  chart.    See  page  203. 

Figs.  32  A  and  B  illustrate  the  disproportion  between  the  tem- 
perature and  pulse  rate  in  a  patient  with  acute  caseous  tuber- 
culosis which  later  went  on  to  death,  but  was  preceded  by  marked 
intestinal  disturbances.  It  will  be  noticed  that  there  is  a  dis- 
proportion between  the  temperature  and  pulse, — the  pulse  being 
comparatively  slow,  considering  the  serious  condition  of  the  pa- 
tient. It  must  further  be  said  that  this  patient's  pulse  was  run- 
ning in  the  neighborhood  of  120  and  130  prior  to  his  entering  the 
institution;  but,  when  put  at  rest,  it  dropped  markedly  and  con- 
tinued between  90  and  100  most  of  the  time.  The  increased 
rapidity  shown  in  chart  B,  beginning  on  the  12th  of  December, 
was  due  to  spontaneous  pneumothorax.  This  rise  in  tempera- 
ture and  pulse  was  due  to  a  limited  pneumothorax,  but  the  extra 
disturbance  was  an  added  factor  in  raising  the  pulse  during  the 
latter  half  of  December.  It  was  very  interesting  to  note  that 
with  the  increase  in  inflammation  in  the  lung  shown  in  the  first 
half  of  chart  B  there  was  not  a  corresponding  increase  in  pulse 
rapidity.  The  fact  that  a  spontaneous  pneumothorax  followed 
this  increased  inflammation  on  the  12th  of  the  month  suggests 
that  the  cause  of  the  increased  temperature  was  to  be  found  in 
the  activity  of  the  tuberculous  process  in  the  lung ;  consequently, 


CORRESPONDENCE  BETWEEN  TEMPERATURE  AND  PULSE 


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210  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

we  must  look  upon  the  pulmonary  involvement  as  being  the  de- 
termining factor  in  causing  this  low  pulse.    See  pages  204  and  205. 

Irritation  of  other  branches  of  the  vagus  will  also  cause  inhibi- 
tory action  upon  the  heart.  Pressing  upon  the  eyeball  and  irri- 
tating the  nasal  mucous  membrane  will  both  cause  slowing  of 
the  heart. 

Opposing  this  inhibitory  action  of  the  vagus  is  the  accelerating 
action  of  the  sympathetics,  either  through  central  stimulation 
by  toxins;  stimulation  by  the  various  emotional  states  which  af- 
fect the  patient ;  stimulation  by  certain  internal  secretions  which 
result  when  the  sympathetics  are  stimulated  or  other  factors 
which  call  for  accelerated  blood  now.  Often  the  sympathetic  ir- 
ritation gains  the  upper  hand  and  a  markedly  rapid  pulse  re- 
sults. 

Fig.  33  illustrates  the  manner  in  which  the  pulse  as  well  as  the 
temperature  is  influenced  by  toxemia.  This  chart  is  that  of  a 
patient  who  is  suffering  from  moderately  active  tuberculosis. 
The  course  of  the  disease  was  interrupted  at  periods  of  from 
two  to  four  or  six  weeks,  with  a  high  temperature.  During  each 
one  of  these  rises  in  temperature  there  was  an  increase  in  pulse 
rate  corresponding  with  that  in  the  temperature  curve.  This  is  il- 
lustrated with  the  rise  of  temperature  which  started  on  the  6th  of 
the  month  and  culminated  on  the  9th.  It  will  be  noticed  how 
the  gradual  increase  in  temperature  and  pulse  rate  followed  each 
other.     See  page  207. 

Figs  34  and  35  illustrate  a  marked  disproportion  between  the 
degree  of  temperature  present  and  the  pulse  rate ;  the  pulse  being 
very  high  considering  the  temperature  curve.  These  patients 
were  both  nervous  patients;  and,  while  not  inclined  to  worry, 
they  were  in  a  constant  state  of  disturbed  nervous  equilibrium, 
which  manifested  itself  upon  the  pulse.  They  both  belong  to  the 
type  of  individuals  with  increased  sympathetic  tonus.  See  pages 
208  and  209. 

Figs.  36,  A  and  B,  are  charts  which  illustrate  sympathetic  ir- 
ritation in  a  patient  who  naturally  is  markedly  vagotonic.  This 
patient  suffered  from  rather  a  widespread  lesion  in  the  right 
lung,  which  made  satisfactory  improvement.  These  are  the  early 
charts  in  the  case.  It  will  be  seen  in  chart  A  that  the  tempera- 
ture was  ranging  between  99°  and  100°.     The  pulse  during  the 


VEGETATIVE   NERVOUS   SYSTEM   AND   SYMPTOMS  211 

first  half  of  the  month  remained  between  70  and  80,  and  dropped 
into  the  sixties.  On  the  14th  of  October  this  patient  began  to 
show  marked  signs  of  nervousness.  She  became  exceedingly  de- 
pressed, discontented,  and  unhappy.  The  effect  is  seen  on  the 
pulse.  Without  further  elevation  in  temperature  the  pulse  in- 
creased in  rapidity,  and,  on  several  occasions,  reached  a  maximum 
of  100°.  This  increased  sympathetic  stimulation  occurred  during 
the  two  weeks  preceding  the  menstrual  period  and  was  probably 
induced  by  the  action  of  the  ovarian  secretion  upon  the  sympa- 
thetic nerves.  It  will  be  noticed  that  in  chart  B  the  pulse  came 
down  into  the  seventies;  but,  on  the  8th  of  November,  showed 
another  elevation,  which  continued  until  the  21st.  The  sympa- 
thetic stimulation  this  time  was  not  so  marked.  The  difference 
was  partly  due  to  the  fact  that  I  had  explained  to  this  patient 
why  she  felt  nervous  and  discontented,  and,  with  this  under- 
standing, she  was  able  to  prevent  a  great  deal  of  the  depression 
which  had  manifested  itself  the  previous  month,  and  which  had 
manifested  itself  more  or  less  frequently  throughout  her  men- 
strual life.    See  pages  212  and  213. 

Intestinal  Tract. — The  antagonistic  action  of  the  vagus  and 
sympathetics  on  the  different  portions  of  the  intestinal  tract  is  ex- 
tremely interesting;  and  our  understanding  of  this  action  will 
aid  greatly  in  forming  an  accurate  clinical  conception  of  the  di- 
gestive capabilities  of  the  tuberculous  patient. 

Early  in  tuberculosis  the  toxemia  present  is  not  of  a  high  de- 
gree, and  its  action  upon  the  sympathetics  is  negligible,  as  com- 
pared with  that  present  in  the  more  advanced  cases.  From  the 
very  first,  however,  vagus  stimulation  seems  to  be  important. 
This  is  shown  in  the  larynx,  in  hoarseness  due  to  interference  with 
the  innervation;  in  the  irritation  which  produces  cough,  and  in 
the  increased  bronchial  secretion.  It  is  likewise  marked  in  the 
intestinal  tract  as  I  shall  now  proceed  to  describe. 

Influence  on  the  Salivary  Flow. — During  tuberculosis,  some- 
times there  is  an  increased  amount  of  saliva  and,  at  other  times, 
there  is  a  decrease.  These  changes  show  more  particularly  in 
some  patients  than  in  others.  There  is  a  double  secretory  nerve 
supply  to  all  the  buccal  secretory  glands,  the  parotid,  submaxil- 
lary, sublingual,  and  retrolingual  glands.     Stimulation  of  either 


212 


NERVOUS   SYSTEM   IN   TUBERCULOSIS 


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214  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

the  chroda  tympani,  or  of  the  superior  cervical  ganglion  will  in- 
crease the  salivary  secretion.  It  would  seem  that,  clinically,  the 
greater  vagus  must  be  the  more  important  secretory  nerve  because 
the  toxemia  which  stimulates  the  sympathetic,  also  the  atropin 
which  inhibits  the  action  of  the  greater  vagus  produces  dryness 
of  the  mouth. 

Tongue  Atrophy. — The  base  of  the  tongue  is  supplied  by  vagus 
fibers  which  pass  through  the  glossopharyngeal  (ninth  cranial) 
nerve.  As  a  result  of  prolonged  chronic  inflammation  in  the  lung 
these  tissues  atrophy  and  when  the  tongue  is  protruded  it  may 
be  pushed  to  the  side.  I  have  long  noted  this  fact  clinically. 
It  can  be  best  determined  in  a  markedly  one-sided  chronic  lesion. 
When  the  symptom  is  present  the  tongue  pushes  toward  the  side  of 
the  more  chronic  and  more  destructive  lesion. 

Motor  and  Sensory  Disturbances  in  Pharyngeal  Structures. — 
Patients  suffering  from  chronic  pulmonary  tuberculosis  suffer 
from  reflexes  which  affect  the  pharyngeal  tissues.  The  vagus 
supplies  the  mucous  membrane  with  sensation  and  the  constrictor 
fibers  with  motor  power.  These  fibers  when  reflexly  disturbed 
may  show  either  sensory  or  motor  phenomena.  The  increased 
sensitiveness  of  the  pharynx  which  is  particularly  noted  when 
a  pulmonary  process  is  acute,  as  during  necrosis  and  cavity  forma- 
tion may  be  accounted  for  in  this  way.  During  this  time  cough 
is  frequently  followed  by  retching  and  vomiting.  Irritation  of 
the  pharynx  takes  place  very  easily  and  is  followed  by  a  further 
vagus  reflex, — vomiting.  The  ease  with  which  the  vomiting  reflex 
may  be  exerted  by  tickling  the  pharynx  is  well  known ;  and  when 
hypersensitive,  the  reflex  phenomena  follow  the  more  readily. 

A  motor  reflex  in  the  pharyngeal  muscles  is  often  noted  late  in 
the  disease.  The  pharyngeal  muscles  atrophy  the  same  as  other 
structures  whose  central  cell  bodies  are  in  reflex  connection  with 
chronic  constant  stimulation.  This  manifests  itself  in  an  irritated 
condition  of  the  nerves  which  show  as  vague  pains  and  in  an 
atrophy  of  the  muscles  and  occasional  disturbance  in  the  act  of 
swallowing. 

Coated  Tongue. — A  dry  coating  of  the  tongue  is  often  noticed 
during  periods  of  temperature  in  cases  where  toxemia  is  a  factor. 


SYMPTOMS    AND    VEGETATIVE    NERVOUS    SYSTEM  215 

The  drying  effect  on  the  salivary  secretions  through  the  sympa- 
thetics  must  be  thought  of  as  an  etiological  factor.  The  fact  that 
this  is  nearly  always  accompanied  by  a  diminution  of  appetite  and 
deficiency  in  gastric  and  intestinal  efficiency  makes  the  cause  the 
more  probable,  for  these  other  conditions  are  likewise  due  to 
deficient  vagus  tonus  or  increased  sympathetic  tonus.  When 
toxemia  has  passed  over,  on  the  other  hand,  a  normal  tongue,  and 
even  increased  appetite,  may  be  seen. 

Stomach. — The  disturbances  on  the  part  of  the  stomach  in  early 
tuberculosis  are  those  which  belong  to  the  class  of  so-called  nerv- 
ous dyspepsias.  The  form  which  seems  most  common,  except  when 
the  patient  is  suffering  from  toxemia  or  mental  depression,  as  I 
shall  describe  later,  is  hyperacidity.  This  is  a  reflex  through  the 
vagus,  the  reflex  coming  from  the  inflamed  pulmonary 
parenchyma.  At  first  the  patient's  digestive  powers  are,  if  any- 
thing, above  par.  This  is  one  reason  why  the  tuberculous  patient 
is  able  to  care  for  such  large  amounts  of  food.  Associated  with 
increased  secretion  there  is  often  an  increased  motility.  This 
shows  itself  now  and  then  in  a  feeling  of  nausea  and  tendency 
to  vomit.  These  conditions,  however,  are  not  continuous.  The 
increased  vagus  tonus  can  be  relieved  by  the  administration  of 
atropin;  and,  following  its  administration,  hyperacidity  and  hy- 
permotility  often  disappear  or  are  ameliorated. 

There  are  also  several  factors  which  come  in  to  cause  sympa- 
thetic stimulation  and  inhibition  of  the  vagus  action,  noticeably, 
toxemia  and  the  depressed  nervous  states  which  are  so  common 
and  which  are  characterized  by  mental  depression,  discourage- 
ment, and  fear.  These  emotional  states  come  and  go  through  the 
disease.  They  are  sometimes  dependent  upon  and  sometimes  in- 
dependent of  toxemia. 

Intestines. — A  similar  condition  obtains  in  the  intestinal  tract 
where  we  have  states  of  increased  vagus  tonus,  causing  increased 
secretion  and  increased  motility,  and  abnormal  sympathetic  irrita- 
tion inhibiting  this  action  and  interfering  with  secretion  and  peri- 
staltic action.  Spastic  constipation  as  a  result  of  increased  vagus 
tonus  is  common  in  early  tuberculosis,  while  the  atonic  type  is  the 
rule  later. 

Definite  effects  of  each  system  are  not  so  easy  to  point  out  in 


216  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

the  intestinal  tract  because  of  the  preponderance  of  stasis  and 
constipation,  which  are  regularly  found  in  general  life  and  which 
affect  so  many  of  those  who  are  afflicted  Avith  tuberculosis  prior 
to  the  time  when  the  disease  becomes  manifest.  We  may  say, 
however,  that,  as  a  rule,  digestion  becomes  more  impaired  and 
stasis  and  constipation  become  more  pronounced  as  the  disease 
advances  and  toxemia  and  the  various  depressive  emotional  states 
become  more  marked.  Thus  it  would  seem  that  early  tuberculosis 
is  a  condition  in  which  increased  vagus  tone  naturally  predomi- 
nates over  sympathetic  stimulation;  and  advanced  tuberculosis  a 
condition  in  which  sympathetic  irritation  seems  to  be  greater  than 
the  vagus  tonus.  The  degenerations  which  occur  after  the  dis- 
ease has  existed  for  a  long  time  are  accountable  for  many  of  the 
symptoms. 

In  offering  this  analysis  of  nervous  action  in  tuberculosis,  I 
realize  fully  that  it  is  impossible  to  always  point  out  the  direct 
relationship  between  cause  and  effect ;  because  we  are  dealing  with 
a  disease  which  produces  dysfunction  on  the  part  of  many  organs 
and  which  results  in  a  multitude  of  conditions  which  might  pro- 
duce symptoms  similar  to  those  which  could  be  explained  at  one 
time  by  irritation  of  the  sympathetics,  at  another  by  irritation  of 
the  vagus.  It  can  be  seen,  however,  that  these  two  systems  are 
to  be  taken  into  account;  and  that,  as  long  as  inflammation  in 
the  lung  exists,  so  long  are  impulses  carried  to  various  organs 
through  these  two  systems,  which,  acting  antagonistically,  dis- 
turb the  normal  equilibrium,  which  is  so  necessary  to  normal 
function. 


CHAPTER  VIII. 

THE  NERVOUS  SYSTEM  CONTINUED:  THE  RELATION- 
SHIP OF   THE   SYMPATHETIC   NERVOUS   SYSTEM 
TO  TOXEMIA  AND  THE  DEPRESSIVE  EMO- 
TIONAL STATES  IN  TUBERCULOSIS. 

The  clinician  must  ever  turn  to  physiology  and  pathological 
physiology  for  the  explanation  of  phenomena  which  he  observes 
in  medicine.  The  study  of  medicine,  however,  increases  greatly 
in  interest  as  he  is  able  to  assign  a  plausible  reason  for  observed 
facts.  Volumes  have  been  written  in  explanation  of  the  phenom- 
ena of  anaphylaxis.  Temperature  has  been  discussed  in  every 
text  book  dealing  with  diseases  accompanied  by  toxic  conditions. 
The  symptoms  which  accompany  toxic  states  are  well  known, 
and  more  or  less  accurately  described,  yet  a  fully  satisfactory  ex- 
planation of  the  rationale  of  their  production  has  not  been  of- 
fered. 

Primarily  I  believe  that  it  is  justifiable  to  state  that  the  symp- 
toms which  accompany  a  disease  are  at  least  partly  associated 
with  the  means  which  the  organism  provides  for  its  defense 
against  that  disease.  It  may  be  difficult  at  times  to  see  how  this 
works  out,  especially  when  the  symptoms  become  so  serious  as 
they  often  do  when  the  organism  succumbs  to  the  disease.  Our 
answer  to  this  is  that  it  is  not  the  symptoms  which  cause  death 
but  the  disease  itself ;  and  that  the  disease  may  become  so  serious 
that  the  very  means  which  have  been  developed  for  the  defense 
of  the  organism  may  become  abnormal  and  even  harmful. 

To  understand  this  better  I  would  cite  instances  of  physical 
defense  in  which  the  means  of  defense  proved  harmful.  At  the 
time  of  the  Lusitania  disaster  the  story  is  told  of  a  woman  and 
three  men  who  seized  hold  of  a  piece  of  wood  which  was  suf- 
ficient to  help  them  all  to  keep  afloat.  Nature  turned  all  the 
latent  forces  within  their  bodies  to  active  working  power  and 
gave  them  almost   superhuman  strength   of  muscle  to  preserve 


218  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

them  from  death ;  but,  in  spite  of  this,  one  by  one  they  let  loose 
their  hold;  and  all  perished  but  one.  The  unnatural  strength 
which  was  thus  developed,  and  which  would  have  saved  everyone 
of  them,  had  the  struggle  not  been  too  long,  ended  in  exhaus- 
tion, and  permitted  the  enemy  against  which  they  were  strug- 
gling, to  overcome  all  but  one ;  and  she  was  nervously  and  phys- 
ically exhausted  for  days,  as  a  result  of  the  struggle.  Many 
instances  are  also  cited  in  the  present  European  war  where  men 
have  been  compelled  to  defend  themselves  by  supreme  effort. 
The  retreat  from  the  Mons  to  the  Marne  is  a  case  in  point.  Phy- 
sical and  nervous  energy  were  developed  in  the  troops  who  made 
that  retreat  to  an  extent  that  seems  incredible.  For  nine  days 
men  marched,  averaging  twenty  miles  a  day,  harassed  continu- 
ally by  an  enemy.  They  were  enabled  to  do  this  because  the 
necessity  of  self-preservation  demanded  it  and  the  latent  powers 
within  them  were  called  into  action  and  every  particle  of  force 
which  the  body  could  muster  was  converted  into  muscular  energy 
to  be  utilized  in  making  their  escape.  This  supreme  effort  was  fol- 
lowed by  exhaustion.  Many  men  fell  by  the  wayside,  and  those 
who  succeeded  in  making  their  escape  were  exhausted  nervously 
and  physically.  Many  of  them  sank  into  an  unconsciousness,  a 
sleep  which  lasted  two  or  three  days;  some  to  waken  no  more. 
In  both  of  these  instances  the  exhaustion  was  a  result  of  the 
overworking  of  the  means  of  defense. 

The  same  is  true  in  infectious  diseases.  The  body  is  confronted 
by  an  enemy.  Its  defensive  powers  are  called  out,  not  for  the 
supreme  physical  effort  only,  but  for  a  chemical  effort,  requiring 
energy  none  the  less.  Bacteria  liberate  foreign  protein  molecules 
when  they  go  into  solution  and  during  their  growth.  These 
molecules  are  set  free  in  the  tissues.  As  a  result  of  chemical  ac- 
tion they  are  destroyed,  liberating  toxic  molecules.  If  these  toxic 
molecules  are  set  free  in  great  numbers  the  organism  may  be  un- 
able to  stand  their  action  and  death  may  result.  When  infectious 
microorganisms  enter  the  body,  if  implantation  results,  the  meta- 
bolic processes  of  the  body  are  increased.  As  a  result  of  this  in- 
creased metabolism,  there  is  an  increase  in  heat  production.  The 
toxic  molecule,  which  results  from  splitting  up  the  protein  mole- 
cule, is  set  free  and  acts  upon  the  cells  of  the  central  nervous 


NATURE  OF  DEFENCE  AGAINST  BACTERIA  219 

system.  It  stimulates  the  vasomotor  centers,  and,  through,  its  ac- 
tion upon  the  sympathetics,  produces  a  constriction  of  the  super- 
ficial vessels,  interfering  with  the  liberation  of  heat.  As  the  com- 
bined result  of  the  increased  oxidation  and  decreased  elimination, 
of  heat,  the  body  temperature  rises.  This  increase  in  tempera- 
ture has  a  tendency  to  check  further  multiplication  and  growth 
of  bacteria.  Whether  or  not  this  is  a  part  of  the  program  of  de- 
fense, it  is  difficult  to  say ;  but  an  increase  in  temperature,  particu- 
larly when  it  reaches  a  maximum  of  100°  or  101°,  or  more,  cannot 
help  exerting  an  inhibitory  influence  on  the  growth  of  bacteria. 

Whenever  the  bodily  forces  are  called  upon  for  defense,  whether 
it  be  to  attack  an  enemy,  to  escape  from  an  enemy,  or  to  fight  an 
infection,  the  processes  which  go  on  within  the  body  are  the  same 
in  principle.  Latent  energy  is  transformed  into  active  working 
energy;  and,  in  order  that  the  protective  forces  of  the  organism 
may  be  as  great  as  possible  where  the  danger  is  serious,  the  in- 
ternal viscera  are  called  from  duty  for  the  time  being,  their  func- 
tion being  temporarily  inhibited  that  the  energy  ordinarily  used 
up  by  them  may  be  devoted  to  defense. 

Crile1  has  shown  that  the  particular  organs  which  are  con- 
cerned in  defense  are  the  brain,  the  adrenal  gland,  the  thyroid 
gland,  the  liver,  and  the  muscles.  These,  he  speaks  of  as  the 
"Kinetic  system,"  a  system  which  is  "evolved  primarily  for  the 
transformation  of  latent  energy  into  motion  and  heat;"  the 
motion  and  heat  being  the  two  forms  of  energy  which  are  util- 
ized by  the  organism  in  defense.  These  organs  are  all  more  or 
less  interdependent  in  their  action.  Cannon2  has  especially 
studied  the  action  of  the  adrenal  glands  and  shown  how,  ow- 
ing to  the  fact  that  it  is  innervated  through  the  sympathetics 
(splanchnics)  its  action  is  dependent  upon  the  same  stimuli 
as  those  which  affect  the  sympathetics  in  general.  He  has 
also  shown  that  the  effect  of  adrenin  which  results  from  this 
stimulation  when  thrown  into  the  circulation  acting  peripherally 
upon  the  myoneural  junction  of  the  sympathetics  is  to  further 
produce  or  prolong  the  same  action  as  results  from  central  sym- 
pathetic stimulation.     Thus,  adrenin  in  the  blood  causes  dilata- 


1The  Origin  and  Nature  of  the  Emotions,  W.   B.    Saunders   Company,   1915;   Man — An 
Adaptive  Mechanism,  The  Macmillan  Co.,  New  York,  1916. 

2Bodily  Changes  in  Pain,  Hunger,  Fear,  and  Rage,  D.  Appleton  &  Co.,  1911. 


220  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

tion  of  the  pupil,  rapid  heart  action,  a  checking  of  the  gastro- 
intestinal secretions  and  motility,  and  a  setting  free  of  glycogen 
from  the  liver,  phenomena,  all  of  which  represent  sympathetic 
stimulation. 

The  central  nervous  system  is  the  constant  recipient  of  im- 
pulses. These  impulses,  if  sufficiently  strong,  call  forth  a  re- 
sponse which  results  in  action.  Every  conceivable  agency  act- 
ing upon  the  body,  whether  it  be  a  toxin,  a  protein,  pain,  joy, 
sorrow,  discontent,  the  pleasure  of  a  beautiful  landscape,  or 
the  horror  of  the  battlefield,  produces  impressions  upon  the  cen- 
tral nerve  cells  which,  when  sufficiently  strong,  produce  action 
in  accordance  with  the  type  of  the  stimulating  agency.  Impulses 
of  lesser  degree  are  received  without  causing  action.  One  peculiar 
characteristic  of  stimulating  agencies  is  their  selective  action 
upon  peripheral  nerves.  One  impulse  may  act  through  the 
somatic  nerves,  another  through  the  sympathetic,  and  still  an- 
other through  the  vagus.  There  are  many  instances  in  which  the 
action  is  even  more  selective  than  this;  where  only  one  portion 
of  the  vagus,  for  example,  or  a  single  brain  center,  is  stimulated. 

Knowing  the  selective  action  of  the  digestive  juices,  and  the 
selective  power  of  body  cells  to  take  from  the  blood  stream  the 
particular  substances  required  for  their  growth  and  function, 
and  to  reject  those  which  are  valueless  or  harmful,  and  appreciat- 
ing the  selective  action  of  the  substances  secreted  by  the  various 
glands  of  the  body,  we  are  prepared  to  believe  that  the  purposes 
of  the  organism  are  best  served  by  a  nervous  mechanism  which 
is  also  selective  in  its  reaction  to  harmful  stimuli. 

We  observe  that  certain  stimuli  in  which  we  are  led  to  believe 
that  primary  action  is  peripheral,  act  principally  upon  the  nasal 
branches  of  the  vagus,  others  upon  the  bronchial,  others  upon 
the  cardiac,  and  still  others  upon  the  gastrointestinal  branches. 
Other  central  stimuli  act  upon  the  sympathetic  and  still  others 
upon  either  the  sensory  or  motor  nerves  supplying  the  skeletal 
structures. 

It  may  be  that  this  should  be  spoken  of  as  a  selectivity  in  re- 
sponse or  reaction  rather  than  in  action;  for,  it  may  be  that 
the  impulses  which  meet  the  nerve  cells  affect  all,  but  only 
produce  response  or  reaction  in  definite  groups.    This  latter  sug- 


HARMFUL    STIMULI   INJURE    NERVOUS    CENTERS  221 

gestion  seems  to  hold  for  those  groups  of  bodies  which  produce 
toxemia  and  anaphylaxis.  The  syndrome  of  toxemia  is  central 
stimulation  plus  the  sympathetic  syndrome  of  inhibited  function 
on  the  part  of  the  internal  viscera;  while  the  syndrome  of  anaphy- 
laxis is  that  of  central  stimulation  plus  the  vagus  syndrome  prob- 
ably caused  by  peripheral  irritation  of  the  nerve  endings  of  the 
particular  branches  of  the  vagus  which  show  the  irritation. 

The  effect  of  toxemia,  worry,  fear,  etc.,  is  to  produce  reaction 
on  the  part  of  the  body  so  that  the  effect  of  those  actions  may  be 
neutralized.  A  long  continued  action  of  these  harmful  stimuli 
causes  overwork  and  overstimulation,  which  leads  to  a  degree  of  ex- 
haustion of  the  protective  mechanism.  This  leads  to  neurasthenia, 
exhaustion  or  perversion  of  the  action  of  the  nervous  system; 
psychasthenia,  exhaustion  or  perversion  of  action  of  the  higher  or 
psychical  centers;  myasthenia,  exhaustion  or- perversion  of  action 
of  the  motor  mechanism ;  in  fact,  we  might  express  this  whole  con- 
dition as  a  general  cellular  and  psychical  exhaustion  or  perversion 
of  action. 

As  a  clinical  picture  we  see  this  in  all  degrees  of  severity.  We 
see  it  as  an  acute  process  in  such  conditions  as  acute  toxemia  and 
shock,  and  as  a  chronic  process  in  such  states  as  the  protracted 
toxemias,  and  the  prolonged  nervous  depressions.  Perverted  ac- 
tion on  the  part  of  the  important  organs  of  the  body  under  such 
circumstances  is  known  to  us  all.  A  study  of  the  changes  in  the 
important  organs  as  a  result  of  these  harmful  stimuli  has  been 
made  by  Crile3  and  his  associates  by  which  they  have  been  able  to 
show  the  effect  of  harmful  stimuli  upon  the  brain,  adrenals,  thy- 
roid, and  liver.  Crile  thus  approaches  the  subject  of  the  effect 
of  harmful  stimuli  (among  which  are  diseased  conditions) "upon 
the  body  by  studying  the  impression  that  these  stimuli  make  upon 
the  mechanism  of  defense.  His  work  shows  that  changes  in  the 
brain,  adrenals,  thyroid,  and  liver  follow  either  marked  harm- 
ful stimulation  of  short  duration,  or  less  severe  stimulation  when 
prolonged. 

With  these  suggestions  before  us  we  are  now  prepared  to  study 
the  syndrome  of  toxemia.  We  must  look  upon  the  symptoms 
which  accompany  toxemia  as  being  a  result  of  the  attempt  of 


sMan — An  Adaptive  Mechanism,  Macmillan,  New  York,   1916. 


222  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

the  body  to  destroy  the  toxins,  as  well  as  a  result  of  the  action 
of  the  toxins  themselves. 

-  When  bacteria,  or  any  other  foreign  protein  enters  the  cir- 
culation, it  is  split  up  into  toxic  and  sensitizing  molecules 
(Vaughan).  The  toxic  molecules  act  upon  the  cells  of  the  cen- 
tral nervous  system  and  cause  them  to  send  out  stimuli,  particu- 
larly through  the  sympathetic  system  to  the  tissues  supplied  by 
it.  The  effect  through  the  sympathetics  is  widespread.  At 
some  period  during  the  toxic  state,  depending  upon  the  degree 
of  toxemia  present,  there  is  a  stimulation  of  practically  all  the 
tissues  and  organs  supplied  by  the  sympathetic  nervous  system. 
This  is  noted  in  the  epidermal  tissues  as:  first,  a  stimulation  of 
the  pilomotor  muscles,  causing  the  condition  of  "goose  flesh" 
which  very  often  appears  preceding  or  during  the  chilly  sensa- 
tions which  result  from  toxemia;  and,  second,  in  the  stimula- 
tion of  the  muscles  to  the  sweat  glands,  causing  an  increase  of 
perspiration. 

There  is  also  a  stimulation  of  the  vasomotor  system,  causing 
vasoconstriction.  There  is  a  stimulation  of  the  sympathetic 
fibers  exerting  an  inhibitory  action  upon  the  internal  organs 
where  activity  is  increased  by  the  greater  vagus  nerve,  as  shown 
by  the  lessening  of  the  gastrointestinal  secretions,  and  by  the 
reduction  in  the  gastrointestinal  motility.  The  same  sympa- 
thetic stimulation  is  shown  in  the  heart  by  the  increase  in  pulse 
rate.  Stimulation  of  the  adrenal  glands  is  shown  by  the  in- 
crease of  secretion  of  adrenin,  which  is  accompanied  by  a  forc- 
ing of  glycogen  from  the  cells  of  the  liver. 

The  effect  of  this  stimulation  is  a  general  inhibition  of  func- 
tion upon  all  the  tissues  supplied  by  the  vegetative  nervous  sys- 
tem. The  purpose  of  the  organism,  for  the  time  being,  is  de- 
fense; consequently,  the  functions  of  organs  which  are  not  im- 
mediately necessary  for  that  purpose,  are  checked.  The  demand 
for  energy  required  by  the  digestive  system  is  temporarily  re- 
moved and  the  needs  of  the  body  are  supplied  by  other  methods. 
This  is  particularly  noted  in  the  fact  that  the  glycogen  stored 
up  in  the  liver  is  brought  out  into  the  circulation  for  consump- 
tion. The  adrenal  glands  are  stimulated,  and  they,  in  turn, 
stimulate  the  entire  mechanism  of  defense,  bringing  the  brain, 


ACTION   OF   TOXEMIA 


223 


the  liver,  and  the  thyroid  gland  into  action  in  the  transformation 
of  latent  energy  into  active  defensive  forces. 

As  a  result  of  this  sympathetic  action,  there  results  a  group 
of  phenomena,  which  make  up  the  syndrome  of  toxemia.  This 
is  the  same,  except  in  minor  details,  no  matter  from  what  source 
the  toxemia  comes.  The  syndrome  varies  according  to  the  de- 
gree of  toxemia  present,  and  whether  the  inoculation  of  toxin 
is  single  or  multiple.  Among  the  most  common  symptoms  be- 
longing to  this  syndrome  are  malaise,  lack  of  endurance,  nervous 
instability,  loss  of  strength,  rapid  heart's  action,  lack  of  appetite, 
furred  tongue,  and  hyposecretion  and  hypomotility  throughout 
the  gastrointestinal  tract.  It  can  be  seen  that  this  group  is 
definitely  the  picture  of  central  stimulation  plus  an  expression 
of  general  discharge  through  the  sympathetic  system. 

While  a  temporary  inhibition  of  function  may  be  permitted, 
and  the  energy  conserved  may  be  utilized  in  defense,  if  long  con- 
tinued, it  appears  to  be  deleterious;  consequently,  sympathetic 
stimulation  should  be  relieved  as  much  as  possible  that  the  vege- 
tative functions  may  go  on  undisturbed;  for,  while  a  temporary 
disturbance  of  these  functions  might  be  advantageous  to  the  in- 
dividual, a  prolonged  disturbance  produces  injurious  results. 

The  sympathetics  are  irritated  under  several  different  cir- 
cumstances in  tuberculosis,  as  follows : 

1.  Whenever  tubercle  bacilli  are  multiplying  or  going  into 
solution, — whenever  they  are  producing  and  liberating  toxins. 

2.  Whenever,  as  a  result  of  the  process,  tissues  break  down 
resulting  in  protein  absorption. 

3.  Whenever  other  bacteria  complicate  the  process  and  give 
off  their  toxins  into  the  circulation. 

4.  When  the  patient  becomes  disappointed,  discouraged  and 
is  dissatisfied  with  his  condition  and  fears  that  he  will  not  get 
well,  when  disturbed  by  business  or  domestic  affairs;  and  when 
suffering  from  any  of  the  depressive  emotional  states. 

From  this  it  can  be  seen  that  toxemias  and  depressive  emo- 
tional states  as  they  occur  in  tuberculosis  act  centrally  and  at  the 
same  time  cause  general  sympathetic  stimulation ;  and  are  produc- 
tive of  inhibition  of  function  of  the  various  internal  viscera,  with 
an  elevation  of  temperature  and  general  loss  of  nervous  and  physi- 


224  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

cal  force.  The  picture  of  general  neurasthenia  manifests  itself 
with  its  irritability  of  nerve  centers  and  general  loss  of  physiologi- 
cal balance  whenever  the  process  is  long  continued. 

Toxemia  is  an  active  force  in  tuberculosis  whenever  the  tuber- 
culous process  is  active.  It  is  most  marked  when  the  process  is 
most  acute.  The  system  gradually  grows  accustomed  to  the 
presence  of  toxins  and  adjusts  itself  by  the  formation  of  a  tol- 
erance or  defense.  When  this  state  has  been  attained  a  consider- 
able amount  of  toxins  may  find  its  way  into  the  circulation 
without  producing  marked  symptoms.  In  fact,  after  the  period 
of  acute  activity  has  passed,  it  is  the  rule  for  the  so-called  toxic 
symptoms  to  disappear.  They  can  be  brought  on  again,  how- 
ever, by  exertion.  Exertion  could  act  either  by  forcing  more 
toxins  out  into  the  circulation  as  is  generally  stated  (so-called 
autoinoculation)  or  by  oxidizing  the  toxins  more  rapidly  or  as 
a  result  of  the  increased  oxidization  attendant  upon  the  extra 
work  produced.  The  tuberculous  patient  who  rests  quietly  is 
free  from  the  symptoms  of  toxemia  as  a  rule,  except  during  the 
periods  of  growth  of  bacilli  and  extension  of  the  process  to  new 
tissue  and  during  the  time  of  active  breaking  down  of  tissue. 
Toxic  symptoms  are  increased  by  exertion  and  diminished  by 
rest;  consequently  rest  is  an  important  factor  in  treatment  dur- 
ing the  toxic  state. 

The  more  persistent  symptoms  belonging  to  the  toxic  group 
are  those  which  belong  particularly  to  the  central  nervous  system 
itself,  those  which  are  due  to  the  partial  exhaustion  of  the  nerve 
cells;  malaise,  lack  of  endurance,  loss  of  strength,  and  nervous 
instability.  These  persist  much  longer,  as  a  rule,  than  the  symp- 
toms on  the  part  of  the  internal  viscera  such  as  rapidity  of  heart 
action,  diminution  of  secretion  and  diminution  of  motility  of  the 
gastrointestinal  tract.  The  organs  of  the  body  seem  to  have  a 
wide  range  within  which  they  can  functionate  fairly  normally; 
and,  they  seem  to  be  able  to  withstand  considerable  abuse  and 
still  carry  on  their  part  in  the  animal  economy. 

The  same  syndrome  is  present  during  the  depressive  emotional 
states  as  during  the  states  of  toxemia,  although  the  symptoms 
are,  as  a  rule,  milder  in  character.  Thus,  the  patient  who  is 
in  pain,  also  the  one  who  is  disappointed,  fearful,  anxious,  dis- 


THE  SYNDROME  OF   TOXEMIA  225 

couraged,  pessimistic  and  homesick,  likewise  the  one  who  is  dis- 
contented, cross,  irritable  and  angry,  suffers  from  a  degree  of 
nervons  exhaustion  and  general  inhibition  of  functions  of  the  in- 
ternal viscera.  These  conditions  depress  the  functions  of  the  in- 
ternal viscera  and  lower  the  power  of  fighting  the  disease.  There- 
fore, pain  should  be  relieved  if  possible  and  the  patient  should  be 
kept  as  cheerful  and  happy  as  possible.  In  a  recent  paper4  I 
discussed  the  relationship  of  the  group  of  symptoms  which  ac- 
companies toxic  conditions  to  the  sympathetic  nervous  system, 
and,  while  I  made  the  discussion  general,  it  applies  to  the  subject 
under  discussion.  I  quote  the  paper  in  full,  although  by  doing 
so,  a  slight  amount  of  repetition  is  unavoidable. 

"The  human  body  under  normal  conditions  has  a  perfect  phys- 
iological balance.  The  relationship  of  one  part  or  organ  is  in 
a  state  of  perfect  balance  with  every  other  part  or  organ.  A 
disarrangement  of  this  equilibrium  produces  pathological  con- 
ditions and  dysfunction.  The  derangements  are  indicated  by 
symptoms  and  signs,  which,  when  grouped,  give  us  a  picture  of 
definite  disease. 

"The  explanation  of  well  known  symptoms  is  often  wanting, 
the  practitioner  being  compelled  to  learn  them  as  a  part  of  the 
symptom-complex,  belonging  to  a  certain  disease  instead  of  being 
able  to  point  out  the  exact  forces  operating  to  produce  them.  An 
etiological  classification  of  symptoms  leads  us  to  a  better  under- 
standing of  the  disease  in  question  and  facilitates  diagnosis. 

"In  analyzing  the  symptoms  in  early  pulmonary  tuberculosis, 
I  found  that  they  could  all  be  classed  etiologically  in  three  groups : 
1,  those  due  to  toxemia ;  2,  those  due  to  reflex  action ;  and,  3,  those 
due  to  the  tuberculosis  process  per  se,  as  shown  in  the  table  on 
page  226. 

"In  this  manner  we  classify  some  twenty-six  symptoms  which 
belong  to  tuberculosis  in  three  groups  so  that  each  symptom  in 
the  individual  group  is  due  to  a  common  etiological  factor. 
Such  a  classification  simplifies  diagnosis.  It  offers  an  explanation 
for  the  fact  which  has  long  been  observed, — that  symptoms  are 
variable  in  that  the  same  ones  are  not  always  present,  and  when 
present,  they  are  not  always  prominent. 


4The  Syndrome  of  Toxemia,  an  Expression  of  General  Nervous  Discharge  Through 
the  Sympathetic  System,  Journal  American  Medical  Assn.,  Jan.  8,  1916,  vol.  Ixvi,  pp.  84 
and  85. 


226 


NERVOUS   SYSTEM   IN   TUBERCULOSIS 


"When  studying  these  three  groups  of  symptoms  I  was  im- 
pressed with  the  fact  that  there  was  nothing  distinctive  of  tuber- 
culosis in  that  group  which  is  due  to  toxemia.  The  same  symptoms 
could  be  due,  as  well,  to  an  infection  of  the  tonsil,  the  prostate, 
the  fallopian  tube,  a  toxemia  from  intestinal  stasis  or  an  acute 
infectious  disease.  They  are,  in  short,  a  part  of  the  syndrome 
of  infections  in  general.  I  was  further  impressed  with  the  fact 
that  the  second  group,  those  of  reflex  origin,  all  point  to  organs 
other  than  the  lung,  but  that  they  belong  to  organs  which  are 
supplied  by  the  vagus  and  sympathetic  nervous  system,  both  of 
which  supply  the  lung.  A  further  analysis  of  the  group  which  is 
due  to  toxemia  shows  that  these  symptoms  are  identical  in  dis- 


Group  I. 

Group  II. 

Group  III. 

TOXEMIA. 

REFLEX   ACTION. 

TUBERCULOUS     INVOLVE- 

Malaise 

Hoarseness 

MENT   PER    SE. 

Lack  of  endurance 

Tickling  in  larynx 

Frequent   and  protracted 

Loss  of  strength 

Cough 

colds 

Nervous  instability 

Circulatory  disturbances 

Spitting  of  blood 

Lack  of  appetite 

Digestive   disturbances 

Pleurisy 

Digestive  disturbances 

Loss  of  weight 

Sputum 

Loss  of  weight 

Chest  and  shoulder  pains 

Temperature 

Eapid  pulse 

Flushing  of  face 

Night  sweats 

Apparent  anemia 

Temperature 

Anemia* 

*Since  writing  this  paper,  I  have  been  able  to  explain  several  other  symptoms  as  be- 
longing to  this  group,  such  as  headache  and  general  aching;  and,  when  the  toxemia  is  very 
severe,  producing  collapse,  there  results:  1,  vasodilatation  (vasomotor  paralysis);  2,  sweat- 
ing; 3,  subnormal  temperature. 


tribution  and  effect  with  a  general  discharge  of  nervous  impulses 
through  the  sympathetic  nervous  system. 

"To  make  this  clearer  it  is  necessary  to  recall  that  the  auto- 
nomic nervous  system  supplies  impulses  to  structures  which  are 
not  controlled  by  the  will.  These  are  the  organs  supplied  by 
smooth  muscle  such  as  the  stomach,  intestines,  blood  vessels, 
ducts  of  glands;  also  certain  organs  possessing  striated  muscle 
fibers  such  as  the  heart,  the  beginning  and  terminal  portions  of 
the  alimentary  canal,  and  the  generative  organs. 

"The  autonomic  system  is  divided  into  three  groups;  1,  the 


THE  SYNDROME  OP  TOXEMIA  227 

cranial  and  bulbar,  which  are  spoken  of  as  the  vagus  system; 
2,  the  thoracic  and  upper  lumbar,  known  as  the  sympathetic 
system;  and  3,  the  lower  lumbar  and  sacral,  known  as  the  sacral 
system.  (In  this  paper  I  used  the  term  autonomic  to  designate  the 
entire  vegetative  system.) 

''The  vagus  system  is  the  system  which  conserves  life.  It  con- 
tracts the  pupil,  increases  salivary  secretion,  slows  the  heart 
beat,  causes  an  increase  of  gastric  and  intestinal  juices,  and, 
furnishes  motor  power  for  the  gastrointestinal  tract.  The  sacral 
system  controls  the  emptying  of  the  lower  bowel  and  bladder  and 
presides  over  the  generative  functions.  The  sympathetic  system 
sends  branches  to  all  organs  supplied  by  the  vagus  and  sacral 
systems;  and  where  the  fibers  from  these  different  systems  meet 
there  is  an  antagonistic  action  between  the  sympathetic  and  the 
other  two  systems.  If  the  sympathetic  stimulation  is  sufficiently 
strong,  it  overcomes  the  vagus  and  sacral  tonus.  If  this  control  is 
only  momentary  or  of  short  duration,  as  it  is  in  fear  and  anger, 
as  shown  by  Cannon5  the  general  strength  of  the  individ- 
ual is  increased.  He  possesses  for  the  time  being,  a  power 
greater  than  normal.  On  the  other  hand,  if  this  sympathetic 
control  continues,  a  general  inhibition  of  function  in  the  organs 
supplied  by  the  sympathetic  system  takes  place  and  the  in- 
dividual's powers  suffer  a  diminution;  thus,  the  dry  mouth,  lack 
of  desire  for  food,  stoppage  of  digestion,  and  rapid  heart's  action, 
which  are  temporary  in  the  presence  of  the  major  emotions,  are 
emphasized  and  prolonged  during  toxemia  and  are  expressed 
as  a  general  malaise,  a  more  or  less  continuous  absence  of  ap- 
petite, coated  tongue,  retarded  digestion,  constipation,  rapid 
heart  action  and  tendency  to  perspiration. 

"While  impulses  may  be  carried  directly  from  the  brain  and 
cord  to  the  skeletal  muscles,  insuring  immediate  and  selective 
response  and  through  the  vagus  and  sacral  systems  through  the 
intervention  of  a  single  ganglion,  causing  response  limited  to  a 
certain  organ;  in  the  case  of  the  sympathetic  nervous  system 
numerous  ganglia  are  interposed  and  the  response  is  shown  in 
widely  distributed  parts.  These  ganglia  act  as  modifiers  or 
transformers  of  the  impulse  and  make  its  distribution  general, 


°Bodily  Changes  in  Pain,  Hunger,  Fear,  and  Rage,  D.  Appleton  &  Co.,  1915. 


228  NERVOUS  SYSTEM  IN  TUBERCULOSIS 

which  accounts  for  the  fact  that  so  many  organs  and  parts  are 
involved  in  sympathetic  irritation. 

"Whether  a  toxemia  acts  wholly  centrally  upon  the  sym- 
pathetic nervous  system  is  open  to  some  question.  While  the 
expression  is  that  of  general  sympathetic  discharge,  yet  we  must 
bear  in  mind  that  it  is  possible  that  this  may  be  partly  due,  or, 
at  least,  partly  prolonged  by  certain  internal  secretions  which 
are  engendered  by  the  same  stimulation  as  that  which  produces 
the  general  sympathetic  stimulation.  Cannon  has  shown  that  the 
emotional  states  such  as  anger  and  fear,  while  being  an  expres- 
sion of  general  sympathetic  discharge,  may  be  kept  up  by  adrenin 
in  the  blood.  The  adrenal  glands  are  supplied  through  the 
splanchnics,  and,  impulses  which  cause  a  general  sympathetic 
stimulation,  stimulate  these  glands  also.  A  minute  amount  of  ad- 
renin poured  into  the  blood  stream  has  the  effect  of  producing 
a  prolongation  of  the  condition  which  is  brought  about  by  direct 
sympathetic  stimulation;  thus  adrenin  will  cause  a  dry  mouth, 
impaired  digestion,  intestional  stasis  and  a  rapid  heart.  That 
toxemia,  like  the  emotional  states,  acts  by  stimulating  the  sym- 
pathetics  and  by  prolonging  the  action  through  the  stimulation  of 
the  adrenals  seems  quite  certain.  It  may  also  be  found  on  further 
study  that  disturbances  in  other  internal  secretions  may  have  a 
part  in  this  general  picture;  but  even  should  this  prove  true,  it 
will  not  alter  the  fact  that  the  syndrome  of  toxemia  is  an  expres- 
sion of  general  sympathetic  discharge." 

Further  studies  show  me  that  the  above  paper  does  not  em- 
phasize sufficiently  strongly  the  fact  that  toxins  and  depressive 
emotional  states  act  centrally,  causing  a  general  irritability  of 
the  central  cells.  The  general  expression  of  inhibition  through 
the  sympathetics,  however,  is  well  emphasized. 

Physiologists  tell  us  that  the  action  of  adrenin  upon  the  internal 
viscera  is  produced  through  peripheral  stimulation  instead  of  cen- 
tral stimulation  of  the  sympathetics.  The  particular  point  in  the 
reflex  arc  which  is  acted  upon  is  the  myoneural  junction  where 
the  nerve  endings  and  the  muscle  cells  join.  P.  J.  Meltzer  and 
Clara  Meltzer6  proved  that  adrenin  acts  peripherally  instead  of 
centrally  by  studying  its  action  upon  the  vasoconstrictors  in  a 


eThe  Share  of  the  Central  Vasomotor  Innervation  in  the  Vasoconstriction  Caused  by 
Intravenous  Injection  of  Suprarenal  Extract,  American  Journal  of  Physiology,  vol.  ix, 
p.  147. 


ADRENIN   ACTS   PERIPHERALLY  229 

rabbit's  ear.  The  vasoconstrictors  to  the  rabbit's  ear  pass  through 
the  sympathetics  from  the  superior  cervical  ganglion,  and  through 
the  auricular  magnus,  a  branch  of  the  third  cervical  nerve.  By 
cutting  the  third  cervical  nerve  and  removing  the  superior  cervi- 
cal ganglion,  connection  with  the  central  nervous  system  was  de- 
stroyed. Regardless  of  this  fact  the  intravenous  injection  of 
adrenin  still  produced  a  constriction  of  the  vessels  of  the  rabbit's 
ear,  showing  that  the  action  must  be  peripheral  instead  of  central. 


CHAPTEE  IX. 
THE  CIRCULATORY  SYSTEM  IN  TUBERCULOSIS. 

A  good  heart  is  the  best  asset  that  a  patient  suffering  from 
tuberculosis  can  have.  It  serves  him  well  during  the  time  when 
he  is  struggling  with  the  disease  as  an  infection  capable  of  ar- 
restment; and  it  usually  proves  to  be  the  determining  factor  as 
the  disease  progresses. 

The  question  of  the  displacements  of  the  heart  as  they  occur 
in  advanced  tuberculosis  will  be  discussed  fully  in  Chapter  XI 
so  it  need  not  be  repeated  here. 

The  heart  begins  to  feel  the  effect  of  tuberculosis  as  soon  as 
the  disease  is  of  sufficient  magnitude  to  cause  an  appreciable 
diffusion  of  toxins  into  the  tissues  or  to  interfere  with  inspira- 
tion by  producing  changes  in  the  elasticity  of  the  pulmonary 
tissue  or  by  reflexly  disturbing  the  muscles  of  respiration,  or 
reflexly  influencing  the  heart  itself  through  its  nervous  mech- 
anism. 

Nervous  Influences  upon  the  Heart  in  Tuberculosis. — It  is  im- 
possible to  understand  the  symptoms  on  the  part  of  the  heart  in 
tuberculosis  unless  we  have  a  definite  understanding  of  its  nerve 
control  and  the  factors  which  are  present  to  influence  this. 

In  discussions  upon  the  heart  in  its  relationship  to  this  dis- 
ease it  is  usually  said  that  a  rapid  pulse  is  one  of  the  early 
signs.  It  is  also  considered  to  be  a  factor  throughout  the  entire 
disease.  This  statement,  however,  must  be  modified,  as  can  be 
readily  seen  by  observing  tuberculous  patients  both  at  rest  and 
during  exertion,  during  the  various  phases  of  the  disease. 

The  pulse  rate  in  tuberculosis  is  variable  because  the  condi- 
tions which  affect  the  nerves  that  innervate  the  heart  are  vari- 
able. 

In  order  to  understand  the  influences  which  act  in  increasing 
and  decreasing  the  rate  of  the  heart  beat  it  is  necessary  to  bear 
in  mind  that  the  heart  is  supplied  by  both  the  sympathetic  and 
vagus  divisions  of  the  vegetative  nervous  system.  The  sympa- 
thetic has  a  tendency  to  accelerate  and  the  vagus  to  slow  the 


NERVE  CONTROL  OF  HEART  231 

heart  action.  Toxemia  acts  by  stimulating  the  sympathetic  nerv- 
ous system  centrally,  consequently  toxemia  manifests  itself  on 
the  part  of  the  heart  by  increased  rapidity  of  contraction.  As 
a  result  of  pulmonary  tuberculosis  we  must  bear  in  mind  also 
that  the  nerve  endings  of  both  the  sympathetic  and  vagus  sys- 
tems are  irritated  by  the  inflammation  in  the  lung  and  that  these 
show  reflex  action  in  the  heart  and  other  visceral  and  somatic 
structures.  On  the  part  of  the  heart,  reflex  stimulation  of  the 
sympathetic  tends  to  increase  the  rapidity  of  contraction,  while 
stimulation  of  the  vagus  tends  to  decrease  it;  consequently,  we 
have  the  heart  subject  to  central  stimulation  of  the  sympathetic 
by  the  toxins,  and  peripheral  stimulation  of  both  the  sympathetic 
and  vagus  by  the  inflammation  in  the  lung.  As  a  result  of  this 
action,  as  a  rule,  the  vagus  tonus  is  overcome  for  the  time  and 
the  heart  shows  increased  rapidity.  When  the  toxemia  has  passed 
over,  however,  the  central  stimulation  of  the  sympathetic  ceases. 
Then  the  heart  is  subject  only  to  the  reflexes  through  the  sym- 
pathetic and  the  vagus  from  the  inflammation  in  the  lung.  It 
must  be  understood  that  I  am  now  speaking  only  of  direct  nerye 
influence.  There  are  many  other  factors  which  come  in  and  will 
be  discussed  in  the  proper  place. 

In  many  patients  the  vagus  and  sympathetic  stimulation  bal- 
ance each  other,  the  normal  equilibrium  is  maintained,  and  the 
normal  number  of  heart  contractions  result.  In  other  cases  the 
vagus  predominates  over  the  sympathetic  and  we  find  the  pulse 
even  slower  than  normal.  In  still  others,  however,  the  sym- 
pathetic action  is  the  stronger  and  the  pulse  remains  rapid. 

It  has  long  been  said  that  a  persistently  rapid  pulse  in  tuber- 
culosis means  a  bad  prognosis.  While  this  is  not  invariably 
true,  there  is  some  ground  for  it  because  it  means  that  the  pa- 
tient's sympathetic  tonus  is  in  the  ascendency;  and  this,  being 
the  inhibitory  system,  causes  a  diminution  in  the  gastrointestinal 
functions  and  in  the  functions  of  all  the  other  important  viscera 
of  the  body.  It  would  be  more  rational  to  state  that  those  pa- 
tients who  are  distinctly  of  the  sympathetic  tonus  type,  or  those 
people  who  have  a  decreased  vagus  tonus,  which  means  practically 
the  same  thing,  are  not  as  able  to  withstand  the  disease  as  those  who 
have  increased  vagus  tonus.  Charts  shown  in  Chapter  VII,  Figs. 
29-36    inclusive,  illustrate  the  peculiarities  of  the  pulse  here  de- 


232  CIRCULATORY  SYSTEM   IN   TUBERCULOSIS 

scribed.  The  particular  characteristics  of  the  pulse  in  early- 
tuberculosis,  which  are  dependent  upon  disturbances  in  the  heart's 
nervous  mechanism,  are:  first,  rapidity  during  periods  of  tox- 
emia ;  second,  either  a  normal,  an  increased  or  a  decreased  rapid- 
ity during  periods  of  quiescence,  while  the  patient  is  at  rest; 
third,  instability  of  the  pulse  on  exertion;  its  reaching  a  higher 
point  and  returning  to  the  normal  slower  than  usual,  being  a 
very  common  condition.    (Figs.  29-36,  pages  200-213.) 

After  acute  toxemia  has  passed  over,  toxic  symptoms  may  con- 
tinue through  faulty  methods  of  living  and  continue  to  show  in 
acceleration  of  the  pulse  rate.  Such  emotions  as  disappointment, 
fear,  anxiety,  discouragement,  as  described  in  Chapter  VIII,  have 
the  effect  of  producing  and  prolonging  the  same  symptom-com- 
plex as  that  produced  by  toxemia,  though,  as  a  rule,  the  symp- 
toms are  not  severe.  Consequently,  if  the  patient  is  discouraged 
and  disappointed  these  conditions  stimulate  the  sympathetic  ner- 
vous system  and  produce  rapid  heart  action.  The  accompanying 
chart  (Fig.  37)  illustrates  this  well.  This  patient  was  on  duty 
as  a  nurse  in  the  hospital.  She  was  suffering  from  tuberculosis 
and  was  impressed  with  the  fact  that  it  meant  death.  After 
examination  I  gave  her  hope  and  told  her  that  she  could  get  well, 
and  firmly  impressed  her  with  the  idea  that  she  would  be  re- 
stored to  health.  She  continued  her  work  just  the  same,  but  the 
effect  of  relieving  her  of  fear  and  its  depressing  action  upon 
the  sympathetic  nervous  system  is  well  shown  in  the  appended 
chart. 

The  influence  of  the  nervous  system  upon  the  blood  vessels 
can  be  well  understood  by  the  fact  that  the  sympathetics  sup- 
ply the  muscular  coats  of  the  blood  vessels  of  not  only  the  in- 
ternal viscera,  but  of  the  skeleton  as  well  with  contractor  fibers. 
Consequently,  anything  that  disturbs  the  sympathetic  nervous 
system  is  apt  to  find  expression  in  the  changes  in  vascular  tone. 

There  are  other  changes  to  be  considered  in  the  production 
of  unstable  heart  action.  It  is  impossible  to  determine  how  much 
of  the  effect  is  produced  by  one  cause  and  how  much  by  another. 
The  problems  become  more  and  more  intricate  as  the  disease  ad- 
vances and  increases  in  complexity.  At  first,  the  general  tis- 
sues of  the  body  are  disturbed  little,  if  any.  At  this  time  the 
heart  muscle  is  sound,  unless  injured  by  other  factors.    What- 


SYMPATHETIC   STIMULATION   RELIEVED  BY   HOPE 


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234  CIRCULATORY    SYSTEM   IN    TUBERCULOSIS 

ever  changes  are  present,  as  a  result  of  the  tuberculous  process, 
are  due  to  the  central  stimulation  of  the  sympathetics  by  the 
toxins;  the  peripheral  stimulation  of  both  the  sympathetic  and 
vagus  systems  by  the  inflammation  in  the  lung;  and  to  the  dis- 
turbance of  the  inspiratory  act,  interfering  with  its  accessory 
aid  to  the  circulation.  Later,  however,  these  causes  are  exag- 
gerated and  to  them  are  added  the  factors  of  malnutrition  and 
general  wasting;  general  degenerative  changes  as  well  as  those 
affecting  the  heart  muscle  and  blood  vessels;  displacement  of  the 
heart;  disturbances  in  internal  secretions;  and  the  destruction 
and  other  changes  in  the  pulmonary  tissue. 

Physiological  Facts. — To  understand  fully  the  effect  of  these 
deleterious  factors  on  the  heart  and  circulation  we  must  have 
accurate  physiological  conceptions.  The  circulation  of  the  blood 
is  for  the  purpose  of  adding  oxygen  and  combustible  materials 
to  the  tissues  and  removing  waste.  This  interchange  takes  place 
in  the  capillaries.  It  is  necessary  that  the  flow  of  blood  through 
the  capillaries  be  rapid  that  this  exchange  may  be  carried  on 
properly.  It  is  further  necessary  that  the  blood  be  conveyed  to 
them  with  adequate  force  and  be  carried  away  with  proper  dis- 
patch. The  blood  pressure  of  the  systemic  arteries  depends  upon 
the  amount  of  blood  delivered  in  systole  and  the  tension  in  the 
systemic  vessels.  It  will  be  understood  from  the  discussion  in 
this  chapter  that  the  output  at  each  systole  is  decreased  and  that 
the  muscular  tone  of  both  heart  and  vessels  is  altered,  particu- 
larly in  the  advanced  disease. 

The  lesser  circulation  varies  somewhat  from  the  systemic.  The 
blood  pressure  here  depends  on  the  same  factors  as  in  the  greater 
circulation,  but  the  tissues  are  so  different  in  texture,  and  the 
conditions  so  different,  that  the  pressure  is  much  less.  The  loose 
spongy  pulmonary  tissue  offers  little  support  in  comparison 
with  that  offered  by  the  solid  organs  and  firm  skeletal  muscles. 
So  does  the  negative  intrathoracic  pressure  offer  a  reduced  re- 
sistance to  the  vessels  within  the  thoracic  cage  as  compared  with 
the  pressure  in  other  parts  of  the  body. 

Both  the  systemic  and  pulmonary  vessels  are  capable  of  enor- 
mous distention.  Experiments  have  been  made  which  show  the 
surprising  fact  that  large  areas  may  be  cut  out  of  the  systemic 
and  pulmonary  circulations  without  apparently  producing  any 


PHYSIOLOGICAL   FACTS    AND    PATHOLOGICAL    INFLUENCES         235 

serious  consequences  in  the  circulation.  Three-fourths  of  the 
pulmonary  circulation  has  been  cut  off  in  dogs1  without  reduc- 
ing the  amount  of  blood  delivered  to  the  left  ventricle ;  while  the 
left  lung  has  been  tied  off  in  the  rabbit  without  causing  a  fall 
in  the  systemic  pressure  (Tigerstedt).  Tigerstedt  suggests  that 
one-half  of  the  pulmonary  area  may  be  cut  off  without  any  ap- 
preciable fall  in  the  systemic  blood  pressure  and  suggests  as  the 
probable  explanation  that  the  vessels  of  the  lung  are  probably 
never  uniformly  filled  with  blood,  there  being  large  areas  of 
the  lung  relatively  empty  which  are  only  properly  filled  when 
large  portions  of  the  pulmonary  area  are  cut  out  of  the  circula- 
tion. The  resistance  of  the  lung  is  normally  small  and  the  blood 
pressure  low. 

Effect  of  Pathological  Reduction  in  Pulmonary  Areas. — While 
experiments  such  as  those  mentioned  above  show  the  wonderful 
powers  of  adjustment  in  the  pulmonary  circulation,  they  must 
not  be  interpreted  as  meaning  that- a  large  portion  of  the  lung 
can  be  cut  out  of  the  circulation  with  impunity.  If  the  same 
amount .  of  blood  is  forced  through  one-half  of  the  pulmonary 
area  in  a  given  time  as  should  be  normally  forced  through  the 
total  area,  it  can  only  be  done  by  an  enlargement  of  the  vessels 
and  an  increase  in  the  power  of  the  right  ventricle.  That  such 
a  condition  would  be  followed  by  a  diminished  oxygenation  of 
the  blood  and  in  that  way  eventually  prove  harmful  to  the  entire 
organism  and  result  in  lessened  tissue  tone,  is  to  be  inferred. 
This  is  the  condition  that  we  find  in  advanced  tuberculosis.  As 
the  disease  progresses  one  area  after  another  is  involved  in 
fibrosis  and  necrosis,  and  the  necessary  accompanying  condition, — 
compensatory  emphysema — until  finally  a  large  portion  of  one 
or  both  lungs  is  destroyed  and  the  circulation  is  greatly  em- 
barrassed. Under  such  conditions  the  systemic  blood  pressure 
is  not  maintained.  It  becomes  progressively  lower,  regardless 
of  hypertrophy  of  the  right  heart  and  rapidity  of  the  pulse. 

Blood  Pressure  in  Tuberculosis. — Blood  pressure  is  lowered 
early  in  the  disease,  although  wide  departures  from  the  normal 
are  rarely  seen  except  in  advanced  cases.  This  shows  that  the 
lowering  of  the  systemic  pressure  is  not  primarily  due  to  an  in- 
ability of  the  right  heart  to  propel  the  proper  amount  of  blood 


1Lichtheim:     Die  Storungen  des  Lungen  Kreislaufes,  Berlin,   1876. 


236  CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 

through  the  lungs  into  the  left  heart,  thus  into  the  general  cir- 
culation on  account  of  lack  of  muscular  force;  although  this 
condition  is  often  finally  attained. 

Pike2  says:  "It  is  my  belief  that  there  are  at  least  four 
mechanisms  involved  in  the  maintenance  of  blood  pressure; 
namely,  (1)  the  vasomotor  nerves,  whose  common  point  or  origin 
lies  in  the  medulla  oblongata;  (2)  the  heart  and  its  nerves — in- 
trinsic, perhaps,  as  well  as  extrinsic;  (3)  the  skeletal  muscles; 
and  (4)  some  property  of  the  tissues  of  the  vessel  walls,  possibly  in- 
dependent of  the  nervous  system,  in  addition  to  those  properties 
directly  under  control." 

From  the  above  quotation  it  is  evident  that  at  least  three, 
probably  all  of  the  mechanisms  which  maintain  blood  pressure, 
are  disturbed  in  pulmonary  tuberculosis. 

It  is  generally  stated  that  toxins  reduce  blood  pressure.  This 
is  untrue  of  toxins  per  se  unless  the  toxemia  be  very  severe. 
Toxins  act  upon  the  vasomotor  center  and  through  the  sympa- 
thetic nervous  system  and  produce  vasoconstriction.  This  is  one 
of  the  causes  of  rise  in  temperature  which  I  have  discussed  in 
Chapter  XXX,  Vol.  II.  The  state  of  toxemia,  however,  after  it  has 
existed  for  a  prolonged  time,  produces  other  conditions  which 
have  a  tendency  to  lower  blood  pressure.  In  early  tuberculosis, 
lowering  of  the  blood  pressure  is  most  probably  due  more  to 
the  lessening  of  the  inspiratory  act  than  any  other  single  factor. 
In  advanced  tuberculosis  many  other  factors  enter,  such  as  de- 
generation of  the  heart  and  wasting  of  the  skeletal  muscles. 

The  effect  of  tuberculosis  upon  the  heart  is  many-sided.  In 
early  tuberculosis  we  have  not  only  the  effect  of  the  toxins  act- 
ing centrally  through  the  sympathetics,  accelerating  its  action, 
but  also  a  peripheral  stimulation  of  both  sympathetic  and  vagus 
fibers  by  the  inflammation  in  the  lung,  the  effect  of  the  former 
being  to  accelerate,  and  the  latter  to  slow  the  heart's  action; 
consequently,  through  the  entire  course  of  pulmonary  tubercu- 
losis there  is  a  disturbed  innervation,  varying  greatly  according 
to  the  extent  of  the  lesion  and  the  degree  of  activity.  Later, 
changes  take  place  in  the  heart  muscle  itself ;  first,  that  of  hyper- 
trophy of  the  right  ventricle  in  order  to  overcome  the  extra  work 
thrown  upon  it  by  the  disease  blocking  off  the  vessels  in  the 


2Nature  of  Surgical  Shock,  American  Journal  of  Surgery,  October,  1914. 


BLOOD   PRESSURE   IN    TUBERCULOSIS  237 

lung ;  but,  later,  degeneration  of  the  heart  muscle,  resulting  from 
toxemia  and  general  malnutrition. 

The  skeletal  muscles,  while  not  particularly  disturbed  at  first, 
sooner  or  later  lose  their  tone,  partaking  of  the  general  wasting 
of  the  tissues  throughout  the  body.  The  loss  of  support  to  the 
vessels  arising  from  decreased  tissue  tone  must,  of  necessity, 
greatly  interfere  with  their  ability  to  maintain  their  normal  tone, 
and  it  would  not  be  at  all  beyond  reason  to  suspect  that  vessel 
walls  are  weakened,  the  same  as  all  other  tissues  of  the  body. 

There  is  no  doubt  that  blood  pressure,  lower  than  normal, 
must  exert  an  unfavorable  influence  upon  the  patient.  In  or- 
der to  maintain  proper  conditions  for  metabolism  to  go  on,  a 
certain  normal  pressure  in  the  circulation  is  demanded.  In  tu- 
berculosis, to  the  extent  that  this  normal  is  reduced,  there  must 
be  interference  with  nutrition.  The  effect  of  the  various  factors 
operating  to  alter  pressure  is  to  cause  a  wide  departure  from  the 
normal  in  the  blood  content  of  various  groups  of  vessels.  The 
blood  remains  stored  up  in  the  venous  reservoirs  of  the  body, 
particularly  in  the  liver  and  splanchnics,  while  the  arteries  are 
relatively  empty. 

The  effect  of  low  pressure  may  be  inferred  from  the  follow- 
ing quotation  from  Pike:3  "Whatever  the  immediate  cause  of 
the  low  blood  pressures  may  be,  it  may  well  become  part  of  a 
vicious  circle.  Even  though  the  blood  be  well  oxygenated  by 
artificial  respiration,  and  the  heart  be  beating  regularly,  a  pre- 
viously damaged  portion  of  the  central  nervous  system:  e.  g., 
the  brain,  after  subjection  to  anemia,  does  not  recover  as  long 
as  the  systemic  blood  pressure  remains  low.  Nor  does  this  fact 
need  surprise  us  when  we  remember  that,  among  the  other  rela- 
tively constant  conditions  of  the  mammalian  body,  a  blood  pres- 
sure varying  but  a  few  millimeters  under  the  various  conditions 
of  activity  from  day  to  day  or  year  to  year  is  an  important 
item.  Any  considerable  variation  from  this  usual  level  is  strong 
presumptive  evidence  of  abnormal  processes  involving  other 
mechanisms  than  that  of  circulation." 

The  failure  of  the  heart  to  meet  the  requirements  of  exercise, 
particularly  sudden  strain  in  advanced  tuberculosis,  can  easily 
be  explained.    The  extra  amount  of  blood  required  for  the  mus- 


8Nature  of  Surgical  Shock,  American  Journal  of  Surgery,  October,  1914. 


238  CIRCULATORY   SYSTEM  IN   TUBERCULOSIS 

cles  during  exercise  is  derived  from  the  splanchnic  area  and  ow- 
ing to  the  lessened  inspiratory  act,  the  conditions  are  such  that 
it  cannot  be  readily  delivered  to  the  right  heart. 

Blood  pressure  is  low  in  all  stages  of  tuberculosis,  although 
the  readings  of  different  observers  show  no  uniformity  on  ac- 
count of  individual  variability.  The  degree  of  fall  in  pressure 
is  modified  by  many  factors,  but  is  progressive  as  the  disease  ad- 
vances. My  findings  in  blood  pressure  are  well  represented  by 
the  statistics  of  162  patients  examined  and  compared  with  20 
non-tuberculous  individuals.4  The  readings  were  made  by  the 
Stanton  sphygmomanometer. 

Sys.  Dias. 

Hg. 


Sys. 

Dias. 

20  non-tuberculous  individuals 

120 

108  mm, 

11  patients  in       I  Stage 

106 

78 

21  patients  in     II  Stage 

108 

81 

.30  patients  in  III  Stage 

103 

75 

While  in  this  table  the  pressure  in  Stage  II  was  higher  than 
that  of  Stage  I,  this  is  purely  accidental.  Had  the  number  of 
patients  been  larger  the  pressure  in  Stage  I  would  have  un- 
doubtedly been  somewhere  between  the  reading  of  106  and  that 
of  120  noted  for  the  non-tuberculous.  The  only  fact  which  I 
wish  to  illustrate  is  that  the  pressure  is  lower  than  normal  and 
that  it  progresses  with  the  disease.  It  is  not  uncommon  in  far 
advanced  cases  to  find  instances  where  the  pressure  falls  to  90 
mm.  Hg.  and  at  times  below  this. 

Extremely  low  pressure  is  associated  with  a  very  low  tissue 
tone.  Patients  having  very  low  pressure  feel  relaxed.  They  lack 
endurance,  are  easily  fatigued,  sometimes  on  the  slightest  exer- 
tion, even  though  not  out  of  bed.  On  motion  they  often  feel 
dizzy  and  faint.  Poor  appetite  and  digestion  are  often  accom- 
paniments. "We  meet  this  when  there  has  been  an  extensive  de- 
structive process  in  the  lung,  associated  with  marked  interfer- 
ence with  the  inspiratory  action  of  the  thorax,  and  consequently 
a  marked  splanchnic  congestion,  a  high  grade  of  toxemia  and 
a  general  wasting.  When  we  recall  that  82  mm.  Hg.  pressure  is 
the  point  of  syncope  we  can  see  that  the  low  pressures  of  ad- 
vanced tuberculosis  are  approaching  it  and  are  inconsistent  with 
feelings  of  well-being. 


4The  Effect  of  Tuberculosis  on  the  Heart,  Archives  of  Internal  Medicine,  October,  1909. 


SMALL  HEART  AND  ARTERIES  239 

These  low  pressures  are  benefited  by  such  lines  of  treatment 
as  abdominal  massage;  treatment  which  will  produce  a  deposit 
of  fat  in  the  abdomen;  adhesive  straps  or  belts  which  increase 
the  intra-abdominal  pressure  and  aid  in  forcing  the  blood  from 
the  splanchnic  areas  toward  the  heart;  also  by  such  remedies  as 
have  a  direct  tendency  to  raise  blood  pressure  such  as  digitalis, 
citrate  of  caffeine  and  suprarenal  extract.  In  the  use  of  digitalis, 
larger  doses  should  be  employed  than  usually  given.  I  not  in- 
frequently given  fifteen  minims  or  more  of  a  standardized  tinc- 
ture three  times  a  day  for  two  days,  then  drop  to  ten  minims  for 
a  period  of  four  or  five  days;  I  then  omit  the  remedy  for  two  or 
three  days  and  resume  the  same  as  before,  keeping  up  its  use 
over  a  considerable  time. 

It  has  been  noticed  that  a  rise  in  blood  pressure  and  clinical 
improvement  go  hand  and  hand.  Some  observers  have  attributed 
the  improvement  in  the  pulmonary  condition  to  the  increase  of 
blood  pressure.  This  is  a  factor  in,  the  increased  well-being  of 
the  advanced  case  as  just  mentioned,  but  it  cannot  be  considered 
as  standing  in  a  causative  relationship  to  the  cure  and  arrest- 
ment of  the  tuberculous  process.  In  early  tuberculosis  when 
the  infiltrations  in  the  lung  disappear,  nerve  tone  improves  and 
the  normal  inspiratory  excursion  is  restored  wholly  or  almost 
wholly,  the  blood  pressure  rises  and  attains  or  approaches  the 
normal.  The  rise  in  pressure  stands  as  a  result,  not  as  a  cause 
of  the  pulmonary  improvement.  In  the  advanced  stage  the  in- 
creased pressure  is  due  to  increased  nerve  stability,  improved  in- 
spiratory action,  improved  nutrition,  and  better  heart  action.  It 
cannot  be  denied,  however,  that  the  increased  pressure  reacts 
and  further  increases  the  patient's  feelings  of  well-being  and  in 
that  way  furthers  his  improvement. 

Small  Heart  and  Arteries. — In  Chapter  XI,  page  301, 1  discussed 
the  question  of  the  small  heart  and  suggested  elsewhere5  that 
it  is  probably  the  result  of  an  embarrassed  inspiratory  act 
through  which  the  heart  is  required  to  accustom  itself  to  a  de- 
creased blood  content,  likewise  a  decreased  output.     Benecke, 


BThe    Small    Heart    in    Tuberculosis:      A    Suggested    Physiologic    Explanation,    Journal 
American  Medical  Association,  April   17,   1915. 


240  CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 

as  well  as  other  pathologists,  has  shown  that  the  same  conditions 
obtain  in  the  arteries,  the  arteries  being  narrower  than  normal. 
It  can  be  seen  how  this  cause  would  operate  to  produce  narrow- 
ing of  the  arteries,  as  well  as  a  reduction  in  the  size  of  the  heart. 
That  the  malnutrition  of  the  late  stages  leads  to  an  atrophy 
of  the  heart  muscle  is  well  established;  but  this  is  entirely  apart 
from  the  small  heart  which  has  been  spoken  of  by  clinicians  and 
which  is  found  in  early  tuberculosis.  Bohland6  in  discussing  this 
question,  states  that  Reuter7  and  Hirsch8  and  Kersten9  proved 
the  presence  of  the  small  heart  by  orthodiagraphic  examination. 
He  says:  "Both  found  in  the  majority  of  tuberculous  subjects 
(62.5-88  per  cent)  hearts  which  were  too  small;  in  fact,  Kersten 
found  hearts  below  normal  in  size  in  62.5  per  cent  of  well  nour- 
ished patients."  Not  only  were  Kersten 's  patients  well  nour- 
ished; but  a  large  number  of  them  were  in  the  first  stage  of 
tuberculosis. 

Hypertrophy  of  Right  Ventricle. — Tuberculosis  presents  sev- 
eral conditions  tending  to  disturb  circulation.  On  the  part  of 
the  pulmonary  circulation  we  have  the  obstructions  in  the  ves- 
sels supplying  areas  of  lung  tissue  of  greater  or  lesser  extent, 
either  by  the  infiltration  and  collateral  inflammation,  or  the 
destruction  of  lung  tissue.  We  also  have  the  embarrassment 
due  to  the  encroachment  upon  the  vessels  which  results  from 
compensatory  emphysema. 

It  is  evident  from  these  conditions  that,  at  least  for  a  long 
time  the  circulatory  burden  in  tuberculosis  is  upon  the  right 
heart.  There  is  an  obstruction  of  a  permanent  character  to  the 
circulation  in  the  pulmonary  vessels.  This  calls  for  permanent 
extra  work  upon  the  right  heart.  In  order  to  measure  up  to  the 
demand  the  muscle  hypertrophies.  The  right  heart  bears  the 
brunt  of  the  disease  and  ultimately  is  the  deciding  factor  be- 
tween life  and  death. 

Thickening  of  Arteries  in  Tuberculosis. — Examination  of  the 
arteries   in   chronic  tuberculosis  shows   them   to   be   thickened.10 


6Handbuch  der  Tuberkulose,  Brauer,  Schroder  und  Blumenfeld,  Johann  Ambrosius  Barth, 
Leipzig,   1915. 

7Dissert.  Miinchen,  1884. 

sDeutsches   Archiv   fur  klinische   medicin,    Bd.    c. 

8Deutsche  medizinische   Wochenschift,    1911. 

10Pottenger:  The  Effect  of  Tuberculosis  Upon  the  Heart,  Archives  of  Internal  Medi- 
cine, October,   1909. 


BLOOD  VESSELS  IN  TUBERCULOSIS 


241 


The  analysis  of  162  patients  examined  with  reference  to  the 
condition  of  the  arteries  showed  the  following  result: 


Duration  of  Illness  from  First  Definite  Clinical  Signs 


CONDITION  OF  RADIALS 

LESS  THAN   1  TEAR 

1    TO    2   YEARS 

MORE  THAN  2  YEARS 

Palpable 

Non-palpable 

14 

14 

20 
21 

60 

33 

These  results  were  based  on  the  examination  of  the  radial 
artery,  and  were  obtained  after  stripping  the  radial  from  below 
upward  with  the  second  finger  of  one  hand  and  above  downward 
with  the  second  finger  of  the  other  hand,  and  then  feeling  the 
radials,  emptied  of  blood,  with  the  forefinger.  Unless  the  pre- 
caution of  stripping  the  vessel  of  blood  is  taken,  the  result  will 
be  unsatisfactory. 

Later  examinations  confirm  these  earlier  observations. 

The  cause  of  the  thickened  arteries  is  most  probably  in  some 
way  related  to  the  toxemia.  Support  for  this  theory  is  seen  in 
the  effect  of  other  toxemias  in  producing  the  same  condition,  and 
the  fact  that  this  condition  is  more  common  in  chronic  cases 
where  the  causative  factors  have  had  a  longer  time  to  act. 

Tuberculous  Lesions  of  the  Blood  Vessels. — Tuberculosis  may 
affect  the  blood  vessels  either  from  within  or  from  without,  and 
the  lesion  may  be  of  all  degrees  of  severity  from  that  of  very 
slight  trauma  to  necrosis.  Sometimes  the  infection  is  followed 
by  an  opening  in  the  vessel  wall  and  hemorrhage;  sometimes 
an  infiltration  results  which  goes  on  to  repair ;  and  sometimes  an 
endarteritis  with  obliteration  of  the  lumen  occurs.  It  seems 
probable  that  many  of  the  hemorrhages  which  we  have  in  tu- 
berculosis, particularly  those  where  only  small  amounts  of  blood 
are  expectorated,  may  be  due  to  the  injury  of  vessels  resulting 
from  the  action  of  toxins.11 

Bacilli  invade  the  endothelial  cells,  give  off  toxins  which  at- 
tract leucocytes  and  thus  form  tubercles  in  the  walls  of  the 
vessels.  Miliary  tuberculosis  is  a  tuberculosis  disseminated 
by  way  of  the  blood  vessels  in  which  many  bacilli  have  escaped 


"Pottenger:      Some   Observations   on   the   Classification   and   Treatment    of   Hemoptysis, 
American  Journal  of  Medical  Sciences,  June,   1914. 


242  CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 

into  the  blood  stream  and  found  lodgment  in  small  vessels.  It 
is  from  just  such  lesions  as  those  here  described  that  the  bacilli 
which  produce  acute  miliary  tuberculosis  come.  The  capillaries 
are  most  commonly  affected,  while  small  veins  and  arteries  are 
less  commonly  so.  Tubercles  may  be  found  in  the  walls  of  any 
of  the  vessels  of  the  body,  including  the  aorta.  This  being  true, 
it  is  surprising  that  miliary  tuberculosis  is  not  a  more  common 
infection  than  it  is.  That  it  is  not,  is  probably  due  to  the  fact 
that  the  vessel  is  often  occluded  by  the  inflammatory  process  so 
that  bacilli  do  not  get  into  the  blood  stream,  and  second  that 
protective  cell  sensitization  and  antibodies  reduce  the  virulence 
of  or  destroy  the  bacilli  which  gain  entrance  to  the  blood  stream 
before  they  find  lodgment  in  the  tissues,  in  those  patients  in 
whom  infection  has  been  present  long  enough  to  build  up  a  spe- 
cific immunity. 

Difficulties  in  Examining  Hearts  in  Tuberculosis. — The  exami- 
nation of  the  heart  in  advanced  pulmonary  tuberculosis  offers 
many  difficulties.  The  landmarks  which  have  been  learned  in 
normal  chests  no  longer  hold  because  the  heart  is  no  longer  sur- 
rounded by  normal  tissues ;  and,  itself,  is  often  displaced. 

One  does  not  always  find,  I  might  say  in  chronic  advanced 
tuberculosis  he  rarely  finds,  the  point  of  greatest  intensity  for  the 
pulmonary  valve  at  the  second  interspace  to  the  left  of  the 
sternum,  or  the  aortic  valve  at  the  second  interspace  to  the  right 
of  the  sternum,  or  the  mitral  at  the  apex  which  is  usually 
found  in  the  fifth  interspace  somewhat  internal  to  the  mammary 
line.  In  the  shiftings  of  position  which  the  heart  undergoes  as 
one  portion  of  the  pulmonary  tissue  wastes  and  contracts  and 
other  portions  enlarge,  the  site  for  the  auscultation  of  these 
valves  shifts  also.  In  order  to  be  able  to  examine  the  valves  it 
is  essential  to  first  outline  the  heart  as  a  whole.  The  outlining 
of  the  area  of  absolute  heart  dullness  is  of  comparatively  little 
value  in  advanced  tuberculosis.  The  information  desired  can  be 
obtained  only  by  knowing  the  accurate  outlines  of  the  organ  as 
it  lies  in  the  chest.  It  must  be  remembered  that  it  is  the  most 
movable  portion  of  the  mediastinum  and  as  such  may  be  shifted 
to  the  right  or  the  left  as  is  demanded  by  the  intrathoracic  com- 
pensation. 


DIFFICULTIES    IN  EXAMINING    HEART  243 

The  points  of  greatest  intensity  for  auscultating  the  pulmon- 
ary and  aortic  valves  may  both  be  on  the  left  of  the  sternum  in 
marked  left  displacement  or  on  the  right  of  the  sternum  in 
marked  right  displacement,  or  in  any  position  between  these 
two,  as  shown  in  Figs.  41  and  42,  Chapter  XI. 

The  visible  pulsation  on  the  chest  wall  must  not  be  taken  for 
the  apex.  Quite  often  it  is  produced  by  the  hypertrophied  right 
ventricle  as  mentioned  above  and  careful  observation  will  show 
that  the  intercostal  space  draws  inward  as  the  ventricle  con- 
tracts, instead  of  being  thrust  outward  as  it  would  be  if  the  im- 
pulse were  caused  by  the  apex.  Under  such  circumstances  the 
apex  will  be  found  a  considerable  distance  to  the  left  of  the 
point  of  pulsation. 

The  inferior  border  of  the  heart  is  also  at  times  lower  than 
normal.  Especially  is  this  true  in  long-chested,  enteroptotic  in- 
dividuals, also  in  those  who  have  forced  the  diaphragm  down  by 
emphysema  and  at  times  when  tuberculosis  develops  in  individ- 
uals who  are  getting  along  in  years,  or  who,  because  of  their  dis- 
ease, age  prematurely.  Suspensio  cordis  is  not  uncommon  in 
such  cases. 

It  is  important  to  bear  in  mind  that  the  valve  sounds  are  great- 
ly influenced  by  their  surroundings,  consequently  they  cannot  be 
compared  as  they  can  be  in  individuals  who  have  no  change  in 
the  pulmonary  tissue.  While  the  valves  at  the  base  of  the  heart 
are  usually  covered,  when  contraction  of  the  pulmonary  tissue 
occurs  at  one  apex  and  this  is  followed  by  enlargement  and  com- 
pensatory emphysema  of  the  other  lung,  one  valve  may  be  di- 
rectly against  the  chest  wall  while  the  other  has  an  additional 
thickness  of  pulmonary  tissue  between  it  and  the  chest  wall. 
Listening  to  these  two  valves  under  such  circumstances  with  ref- 
erence to  comparing  their  intensity,  can  give  none  but  erroneous 
information. 

Consolidation  of  lung  tissue,  emphysema  and  cavities  affecting 
the  tissues  adjacent  to  the  valves  also  affect  the  character  of  the 
tones. 

Organic  Heart  Lesions  and  Tuberculosis. — If  we  accept  the  idea 
that  clinical  tuberculosis  is  an  accident  which  may  happen  to 
any  member  of  the  human  family,  we  will  not  be  far  from  the 


244  CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 

truth;  and,  further,  we  will  be  ready  to  look  for  about  the  same 
general  complications  that  we  would  expect  in  the  same  num- 
ber of  non-tuberculous  individuals,  unless  there  be  some  specific 
reason  why  such  complications  militate  against  tuberculosis. 

It  is  quite  generally  accepted  that  all  such  organic  heart  lesions 
as  from  their  nature  produce  hyperemia  of  the  pulmonary  tis- 
sue, are  antagonistic  to  the  development  of  pulmonary  tubercu- 
losis. This  does  not,  however,  preclude  the  possibility  of  such 
infection  taking  place,  or  the  possibility  of  such  an  infection 
developing  into  active  clinical  disease  when  the  infection  has  oc- 
curred; for  all  such  protective  conditions  must  be  looked  upon 
as  being  more  or  less  relative. 

I  have  met  with  a  number  of  instances  of  such  heart  lesions 
in  tuberculosis  and  my  experience  with  them  has  been  unfavor- 
able ;  so,  while  they  may  render  a  relative  resistance  to  the  bacil- 
lus, yet  I  cannot  feel  that  the  hyperemia  produced  is  a  factor 
which  can  be  at  all  compared  with  the  aid  in  arrestment  which 
comes  from  a  normal  heart. 

Heart  Bruits. — The  heart  tones  in  tuberculosis  are  often  im- 
pure. Sometimes  a  distinct  bruit  is  present  which  partially  or 
wholly  displaces  the  heart  tone.  Sometimes  it  is  heard  best  on 
ordinary  inspiration,  sometimes  it  is  eliminated  by  forced  in- 
spiration. 

The  character  of  these  bruits  varies,  but  for  the  most  part  they 
are  soft.  They  cannot  be  positively  separated  from  organic  heart 
bruits.  In  fact,  some  writers  believe  that  all  bruits  which  take 
their  origin  from  the  valves  are  produced  by  some  abnormal 
vibration  of  the  valves  or  the  adjacent  vessel  walls.  Aside  from 
the  bruits  which  cannot  be  separated  from  the  heart  valves  there 
are  others  which  are  unmistakably  caused  by  pleuropericardial 
adhesions  and  others  due  to  kinking  and  encroaching  upon  the 
lumen  of  the  vessels  by  the  pathological  changes  present. 

Degeneration  of  Heart  Muscle. — The  hypertrophied  heart  is 
able  to  meet  the  demands  of  the  circulation  at  first;  but,  as  the 
changes  in  the  lung  become  more  widespread,  a  time  comes  when 
any  extra  exertion  is  met  with  difficulty  and  cardiac  weakness 
of  a  greater  or  lesser  degree  manifests  itself.  This  is  the  greater 
when  the  disease  is  not  only  widespread  but  active;  for,  during 


DEGENERATION  OF  HEART  MUSCLE  245 

this  time  malnutrition  is  increasing  and  poisons  are  being  poured 
out  into  the  tissues,  both  of  which  cause  degeneration  of  the  heart 
muscle  along  with  other  tissues. 

Strangely,  the  heart  in  tuberculosis  has  not  received  as  much 
consideration  as  it  deserves.  This  has  been  due  to  our  narrow 
view  of  tuberculosis,  looking  upon  it  as  a  disease  of  the  lungs, 
when,  in  reality,  it  is  an  infection  of  the  pulmonary  tissue  from 
which,  at  least  in  the  advanced  stages,  every  organ  and  cell  of  the 
body  is  injured.  The  heart  comes  in  for  an  unusual  amount  of 
disturbance,  both  in  its  texture  and  function. 

I  have  spoken  of  the  small  heart  which  is  found  in  tubercu- 
losis, even  in  the  early  stages  and  have  given  a  physiological  ex- 
planation for  it.  There  is  also  an  atrophy  of  the  heart  in  tuber- 
culosis which  occurs  as  a  late  manifestation  being  a  part  of  the 
general  malnutrition  and  muscle  wasting. 

The  result  of  prolonged  toxemia  in  tuberculosis  finally  shows 
upon  the  heart  muscle.  As  Satterthwaite12  says:  "We  can  now 
say  that  all  toxemias,  acute  or  chronic,  cause  dyscrasias  and  hy- 
peremias if  long  continued  or  severe,  and  other  conditions  to  be 
mentioned  later,  produce  definite  morbid  changes  in  the  heart 
walls,  evanescent  or  permanent,  as  the  case  may  be. ' '  This  fact 
calls  for  special  attention  to  the  heart  in  dealing  with  this  dis- 
ease. All  things  else  being  equal,  the  patient  with  the  good  and 
well  cared  for  heart  has  a  decided  advantage  in  his  struggle  for 
overcoming  tuberculosis  and  particularly  advanced  tuberculosis. 

The  subject  of  valvular  lesions  is  of  comparative  insignificance 
to  the  condition  of  the  myocardium  itself  in  tuberculosis ;  for  the 
majority  of  deaths  in  this  disease  are  due  to  an  exhausted  heart 
muscle.  The  changes  in  the  muscle  substance  are  not  as  evident 
in  a  slow  going  toxemia  like  tuberculosis  as  they  are  in  a  disease 
in  which  the  toxemia  is  of  a  very  high  grade  such  as  diphtheria ; 
yet,  they  are  no  less  a  factor  in  determining  the  outcome  of  the 
disease.  The  changes  in  the  muscle  substance  in  tuberculosis  are 
general,  as  a  rule;  and  the  ultimate  effect,  no  less  than  in  acute 
toxemia,  is  to  interfere  with  the  contractility  of  the  muscle, 
reducing  the  heart  power. 

Unfortunately,  in  advanced  tuberculosis,  there  is  no  way  of 


"Cardio- Vascular  Diseases,  New  York,  1912. 


246 


CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 


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248  CIRCULATORY   SYSTEM  IN   TUBERCULOSIS 

relieving  the  work  which  is  thrown  upon  the  right  ventricle. 
Whatever  embarrassment  exists  as  a  result  of  blocking  off  and 
obstructing  the  flow  in  the  blood  vessels  of  the  lung  is  perma- 
nent; so,  the  only  way  of  affording  relief  is  through  increasing 
the  strength  of  the  heart  itself,  and  guarding  it  against  all  un- 
necessary strain. 

Clinical  Evidence  of  Failing  Heart. — The  symptoms  which  first 
appear  when  the  heart  begins  to  weaken  under  the  strain  in  tu- 
berculosis are  rather  vague  and  easily  go  unrecognized.  It  is 
much  easier  to  look  back  and  ascribe  to  them  their  proper 
significance  than  it  is  to  recognize  them  at  the  time.  The  symp- 
toms which  I  have  noted  most  commonly  are,  nervousness,  anx- 
iety, insomnia,  lagging  appetite,  and  at  times,  poor  digestion. 
These  symptoms  can  be  caused  by  so  many  conditions  that  un- 
less one  has  the  heart  in  mind  the  true  cause  will  most  likely 
be  overlooked. 

The  pulse  at  the  same  time  becomes  soft  and  weak  and  the 
heart  tones  become  weak  on  auscultation.  But  this  latter  char- 
acteristic is  not  always  readily  discovered,  because  the  sounds 
may  have  been  weak  previously.  These  symptoms  are  often 
present  before  any  marked  dilatation  can  be  determined;  this, 
with  precordial  pain  usually  being  a  later  manifestation.  Some 
increase  of  the  pulse  rate  usually  accompanies  the  early  signs 
of  weakened  heart,  but  not  the  progressively  rapid  pulse  noted 
at  the  time  of  acute  dilatation.  On  examination  an  enlargement 
of  the  heart  from  left  to  right  is  made  out  on  palpation  and 
percussion. 

Pigs.  38  and  39  show  the  way  in  which  the  pulse  and  tem- 
perature curve  separate  in  terminal  dilatation  of  the  heart.  As 
the  heart  becomes  more  and  more  unable  to  do  its  work  it  con- 
tracts less  forcibly  and  more  rapidly,  the  body  becomes  less  and 
less  able  to  react  and  so  the  temperature  falls  lower  and  lower1 
until  death  results.    See  pages  246  and  247. 

Myocardial  weakness,  as  it  affects  the  right  heart,  produces  a 
very  different  picture  from  weakening  of  the  left  heart.  Dyspnea 
is  not  a  very  prominent  symptom  when  the  right  heart  is  at 
fault,  except  when  the  heart  is  called  upon  to  measure  up  to 
an  extra  exertion.    It  is  a  marked  symptom  of  weakness  of  the 


TREATMENT    OF    FAILING    HEART  249 

left  heart,  however,  even  when  the  patient  is  at  rest.  Stasis, 
in  the  systemic  veins,  however,  is  regularly  present  in  weak- 
ness of  the  right  heart,  but  not  regularly  present  in  weakness 
of  the  left.  Pulse  disturbances  are  present  in  both.  When 
dyspnea  and  venous  stasis  are  both  present,  together  with  pulse 
disturbances,  it  is  evidence  of  weakness  of  the  entire  heart. 
Death  from  tuberculosis,  being  usually  a  right  heart  death  is 
peaceful  and  painless. 

Treatment  of  Failing  Heart. — Not  being  able  to  relieve  the 
load  on  the  right  ventricle  we  can  only  strengthen  it  and  make 
as  little  demand  upon  it  as  possible.  In  order  to  accomplish 
the  latter,  rest  in  bed  should  be  enforced.  It  will  be  recalled 
that  the  amount  of  oxygen  made  necessary  by  arising  from 
the  recumbent  to  the  erect  position  is  doubled  and  the  amount 
to  start  going  is  quadrupled.  This  can  only  be  furnished  by 
the  heart  increasing  its  output  of  blood  in  a  given  time.  Con- 
sequently, rest  in  the  recumbent  position  is  one  of  the  most 
valuable  aids  to  such  a  heart,  for  it  relieves  it  of  all  remov- 
able load. 

For  the  heart  muscle  itself  I  have  great  confidence  in  the 
use  of  digitalis  and  citrate  of  caffeine.  If  the  early  symptoms 
mentioned  above  are  recognized  and  the  patient  is  put  in  the 
recumbent  position  and  given  digitalis  in  proper  doses,  the  crisis 
can  often  be  averted.  Digitalis  strengthens  the  heart's  con- 
tractions and  in  this  way  probably  affords  better  nutrition 
to  the  organ;  but,  whether  this  is  the  explanation  or  not,  I 
have  great  confidence  in  its  use.  If  digitalis  is  to  be  used,  it 
should  be  used  in  doses  sufficiently  large  to  produce  an  ef- 
fect. I  use  a  standardized  tincture  in  doses  of  x  to  xx  minims 
three  times  a  day  until  the  pulse  improves  or  the  physiological 
effect  is  reached.  This  is  generally  shown  by  a  nausea  or  ir- 
regularity of  the  heart.  I  then  discontinue  the  remedy  for 
three  days  and  then  repeat  again,  giving  the  remedy  three 
or  four  days  and  then  withholding  it  for  a  like  period.  Citrate 
of  caffeine  can  be  given  in  in  grain  doses  every  four  hours  and 
continued  as  long  as  necessary. 

The  patient  should  be  fed  nourishing  food  in  concentrated 
form.     The  bowels  should  be  kept  free  to  relieve  any  toxins 


250  CIRCULATORY   SYSTEM   IN   TUBERCULOSIS 

that  can  be  removed  through  the  alimentary  canal.  The  im- 
portant thing  in  the  handling  of  these  cases  is  to  recognize 
them  early,  and  to  treat  them  properly.  These  degenerative 
changes  in  the  heart  muscle  may  threaten  the  patient's  life  and 
yet  the  heart  may  recover  itself  as  the  patient  improves. 


CHAPTER  X. 
THE  DIGESTIVE  SYSTEM  IN  TUBERCULOSIS. 

General  Observations  on  Nutrition. — How  different  our  con- 
ception of  nutrition  and  its  problems  since  we  have  come  to 
learn  that  digestion  is  more  than  the  dissolving  of  food  by 
salivary,  gastric,  and  intestinal  ferments.  Substances  of  all 
kinds  enter  the  stomach  as  food,  substances  which,  if  ab- 
sorbed in  the  state  in  which  they  are  ingested  would  completely 
disorganize  the  entire  cellular  system.  The  function  of  the 
gastrointestinal  juices  is  to  break  down  the  many  compound 
substances  which  are  eaten  as  food  and  to  reduce  them  to  sim- 
ple substances  which  the  body  can  utilize.  In  the  form  in 
which  they  are  ingested  many  of  them  are  not  foods,  although 
they  contain  substances  which  may  be  converted  into  foods 
and  utilized  in  building  up  cells  and  furnishing  energy  for 
running  the  human  machine. 

The  protective  action  of  the  gastrointestinal  ferments  is  a 
very  important  part  of  its  digestive  function.  Our  admiration 
for  nature's  protective  program  for  man  is  greatly  increased 
by  our  better  understanding  the  protective  plan  of  the  diges- 
tive tube. 

The  heterogeneous  masses  which  are  ingested  are  broken  down 
and  split  up  into  substances  which  the  organism  can  utilize 
and  those  which  it  cannot.  The  latter,  if  absorbed,  would  be 
harmful.  The  former,  in  order  to  be  properly  utilized  must 
be  carried  to  certain  structures  to  be  further  elaborated.  The 
cells  of  the  mucous  membranes  of  the  digestive  tube  are  en- 
dowed with  such  defensive  powers,  we  almost  feel  like  saying 
selective  intelligence,  that  they  pick  up  those  particles  that 
the  body  cells  can  utilize  and  refuse  to  take  those  which  it 
cannot  use.  Not  only  this,  but  different  cells  pick  up  differ- 
ent substances;  thus  the  fats  are  absorbed  and  carried  through 
the  lymphatics  to  the  blood,  while  the  substances  derived  from 


252  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

carbohydrates  are  taken  up  by  the  blood  and  carried  to  the 
liver.  Should  any  substance  which  is  not  in  harmony  with 
the  tissues  gain  entrance  to  them,  the  cells  with  which  they 
come  in  contact  outside  of  the  digestive  tract,  form  defensive 
ferments  and  split  them  up  into  substances  which  may 
be  utilized  as  food  and  other  substances  which  cannot.  These 
latter  are  then  acted  upon  further  and  further  until  they  are 
rendered  harmless,  if  that  be  possible;  or,  if  not,  until  they  are 
excreted  from  the  body,  or  gain  mastery  over  it.  Abderhalden's 
discussion  of  the  defensive  ferments  produced  by  the  cells  clarifies 
some  of  the  problems  of  human  existence  and  sheds  light  upon 
questions  of  maintaining  the  body  cells  in  a  state  of  equilibrium.1 

Nutrition  in  Tuberculosis. — The  question  of  nutrition  in  the 
tuberculous,  the  same  as  in  the  healthy,  comes  far  from  being 
wholly  a  question  of  what  or  how  much  a  patient  eats,  but  has 
to  do  with  the  entire  question  of  metabolism.  Faulty  nutri- 
tion may  be  due  among  other  things  to  pathological  conditions 
in  the  gastrointestinal  tract,  such  as  disturbances  in  secretion, 
or  motility,  or  any  acute  inflammatory  disease  affecting  the 
canal;  errors  in  diet  consisting  of  either  eating  wrong  food  or 
food  in  improper  quantities,  or  in  an  improper  manner;  degen- 
erative changes  in  the  body  cells  which  interfere  with  either  the 
absorption  of  food  particles  from  the  alimentary  tract  or  the 
proper  exchanges  between  the  blood  and  the  tissues ;  pathological 
conditions  in  the  blood  itself;  interference  with  the  rapidity  of 
blood  flow;  and  a  general  lack  of  harmony  in  the  function  of 
the  various  important  systems  of  the  body. 

Pathological  changes  in  the  gastrointestinal  tract,  as  they 
are  found  in  tuberculosis  present  several  different  conditions, 
the  ultimate  effect  of  which  in  each  case  is  the  interference  with 
proper  absorption  of  nutriment.  An  almost  constant  condition 
in  the  alimentary  tract  in  tuberculosis  is  a  passive  congestion. 
Resulting  from  the  insufficient  motion  of  the  diaphragm  and 
other  inspiratory  muscles  there  is  always  more  or  less  splanchnic 
congestion  present,  the  degree  varying  with  the  amount  of  dis- 
turbance in  inspiration.  This  lessening  of  the  inspiratory  act 
causes  the  blood  flow  to  be  retarded  through  all  the  abdominal 


iAbderhalden :     Defensive  Ferments,  William  Wood  &  Co.,  New  York,   1914. 


FACTORS  INTERFERING  WITH  NUTRITION  253 

organs  and  favors  a  general  blood  and  lymph  stasis,  which  inter- 
feres with  the  secretory  function  of  the  digestive  glands,  the 
motor  function  of  the  gastrointestinal  walls,  and  the  absorp- 
tion of  nutriment  from  the  alimentary  canal.  The  amount  of 
disturbance  due  to  these  conditions  varies  from  that  which  is 
scarcely  discernible  clinically,  to  a  very  markedly  altered  func- 
tion in  some  patients  who  are  suffering  from  more  advanced 
lesions.  Not  only  do  we  have  a  passive  congestion  as  a  result 
of  deficiency  in  the  respiratory  act,  but  also  as  a  result  of 
nervous  influences  and  weakened  heart  action,  the  latter  particu- 
larly in  advanced  tuberculosis. 

Displacement  of  the  various  organs  is  also  very  common  in 
tuberculosis.  This  is  particularly  true  in  the  advanced  disease 
as  a  result  of  malnutrition  and  the  consequent  absorption  of  the 
intra-abdominal  fat,  the  general  weakening  of  the  musculature  of 
the  abdominal  wall,  and  the  wasting  of  the  tissue  supports  of  the 
various  intra-abdominal  organs.  Aside  from  this  we  must  also 
consider  the  effect  of  the  pathological  process  above  the  di- 
aphragm. The  diaphragm  is  often  displaced  and  pushed  down- 
ward by  compensatory  emphysema  and  at  times  by  pleural  ef- 
fusions and  pneumothorax.  Constant  coughing  also  has  an  in- 
fluence in  forcing  the  abdominal  organs  downward.  Probably, 
what  is  of  greater  importance  than  the  ptosis  itself  in  these 
cases  is  the  reduced  intra-abdominal  pressure  under  which  the 
abdominal  organs  are  compelled  to  work  as  a  result  of  this  loss 
of  tissue  and  tissue  tone. 

This  ptosis  affects,  at  times,  all  the  abdominal  organs.  In 
advanced  conditions  it  is  not  uncommon  to  find  the  stomach 
resting  on  the  pubes;  the  cecum  and  transverse  colon,  together 
with  the  small  intestine  wedged  tightly  into  the  pelvic  cavity,  and 
the  lower  pole  of  the  right  kidney  below  the  level  of  the  um- 
bilicus. A  dilated  cecum  is  also  frequently  found.  These 
ptosed  organs,  however,  often  functionate  well  and  show  no 
symptoms  directly  referable  to  the  ptosis  itself. 

Atony  and  dilatation  are  very  common  in  advanced  cases. 

The  gastrointestinal  tract  is  also  subject  to  many  reflex  dis- 
turbances, the  afferent  impulse  traveling  from  the  pulmonary 
ends  of  the  vagus  and  possibly  the  sympathetic,  if  we  follow  the 


254  DIGESTIVE   SYSTEM  IN   TUBERCULOSIS 

Continental  physiologists,  and  the  efferent  being  transmitted 
through  the  gastrointestinal  branches  of  the  vagus  and  sympa- 
thetic, to  the  ganglia  which  lie  in  the  walls  of  the  organ.  I  have 
recognized  this  gastric  vagus  reflex  from  the  lung  in  several  in- 
stances of  hyperacidity  which  were  increased  by  the  focal  re- 
action following  large  doses  of  tuberculin.  I  have  also  seen  it 
in  numerous  instances  during  cavity  formation  in  the  lung, 
where,  as  a  result  of  irritation  of  the  pulmonary  branches  of  the 
vagus,  hyperacidity,  reflex  vomiting,  and  spasticity  of  the  colon 
were  produced. 

Neither  must  we  forget  the  effect  of  toxins  on  the  gastroin- 
testinal tract.  These  have  a  two-fold  action.  They  act  cen- 
trally through  the  splanchnics,  exercising  an  inhibitory  influ- 
ence upon  digestive  activity  in  general;  and,  particularly  late 
in  the  disease,  cause  degeneration  of  the  cells  of  the  organ. 

Tuberculosis  of  the  various  portions  of  the  intestinal  tract  and 
of  the  liver,  pancreas,  and  spleen,  must  also  be  considered  as 
part  of  the  pathology  which  must  be  reckoned  with. 

The  Digestive  Tract  and  the  Vagus  and  Sympathetic  Nervous 
Systems  in  Tuberculosis. — The  part  which  the  nervous  system 
plays  in  the  production  of  symptoms  on  the  part  of  the  gastro- 
intestinal canal  during  the  course  of  clinical  pulmonary  tuber- 
culosis, is  a  very  important  one.  As  all  internal  viscera  are 
innervated  by  both  the  vagus  and  sympathetic  divisions  of  the 
vegetative  system,  and  as  these  divisions  antagonize  each  other 
in  every  viscus  in  which  they  meet,  as  described  more  fully  in 
Chapter  VII,  it  behooves  us  to  study  carefully  the  effect  of  cen- 
tral or  peripheral  stimulation  of  either  of  these  systems  which 
might  occur  as  a  result  of  the  inflammation  in  the  lung. 

As  I  have  shown  elsewhere2  and  discussed  in  Chapter  VIII, 
the  syndrome  of  toxemia  as  expressed  clinically  is  that  of  gen- 
eral sympathetic  inhibition.  Its  effect  is  that  of  a  central 
stimulation  of  the  sympathetic  system;  and  its  manifestations 
are  as  widespread  as  the  organs  innervated  by  it. 

No  matter  what  the  source  of  the  toxemia,  the  expression 
is  the  same. 


2The  Syndrome  of  Toxemia:  An  Expression  of  General  Nervous  Discharge  Through 
the  Sympathetic  System,  Journal  American  Medical  Association,  Jan.  8,  1916,  vol.  lxvi, 
pp.  84  and  85. 


VAGUS  AND   SYMPATHETIC   TONUS   IN   ALIMENTARY   CANAL      255 

On  the  part  of  the  gastrointestinal  canal,  toxemia  manifests 
itself  in  inhibition  of  action.  This  is  the  system  of  nerves  which 
diminishes  salivary  secretion,  relaxes  the  esophagus,  relaxes  the 
stomach,  inhibits  gastric,  intestinal,  hepatic,  and  pancreatic  se- 
cretion, relaxes  the  intestinal  wall  and  decreases  the  motility 
of  the  gut.  "When  toxemia  is  present,  the  sympathetics  are  cen- 
trally stimulated  by  the  toxins  and  peripherally  by  the  extra 
adrenin  which  results  from  the  splanchnic  stimulation,  and  we 
have  a  chain  of  symptoms,  varying,  of  course,  according  to  its 
severity,  such  as;  a  decrease  in  appetite,  coated  tongue,  di- 
minished gastric  and  intestinal  secretions,  and  a  deficient  gastric 
and  intestinal  motility  resulting  in  stasis  and  constipation. 

In  tuberculosis  the  degree  of  toxemia  varies  greatly  with  the 
character  of  the  disease ;  so  do  the  symptoms  on  the  part  of  the 
gastrointestinal  tract.  Sometimes  they  are  very  severe  and  again 
they  are  negligible.  Sometimes,  even  when  a  marked  degree  of  tox- 
emia is  present,  no  noticeable  symptoms  of  gastric  or  intestinal 
origin  will  be  noted.  This  can  be  explained  on  a  rational  basis  by 
bearing  in  mind  that  tuberculosis  is  an  inflammation  in  the 
lung,  which  irritates  the  pulmonary  nerve  endings  belonging 
to  the  vagus;  and,  at  the  same  time,  stimulates  the  cells  of  the 
sympathetic  division  of  the  vegetative  system,  and  that  while 
both  of  these  produce  action  in  the  gastrointestinal  tract,  no  dis- 
turbance in  equilibrium  results. 

Peripheral  sympathetic  stimulation,  like  central  stimulation 
of  the  same  division  of  nerves  may  possibly  cause  inhibition  of 
function  in  those  organs  which  come  in  the  path  of  its  reflex 
action.  Whenever  a  toxemia  stimulates  the  central  nerve  cells 
of  the  sympathetic  in  pulmonary  tuberculosis,  the  inflamma- 
tion at  the  same  time  stimulates  the  peripheral  filaments  of  the 
vagus.  The  vagus,  being  the  division  of  the  vegetative  system 
which  is  conservative  in  its  action,  when  stimulated  to  a  moder- 
ate degree,  opposes  the  inhibiting  influence  of  the  sympathetic 
and  in  many  instances  wholly  counteracts  it. 

Appetite. — The  appetite  is  decidedly  variable  in  tuberculosis. 
During  the  periods  of  general  depression,  such  as  those  which 
are  manifested  by  discontent,  discouragement,  anxiety,  fear  and 
during  pain;  and  also  during  periods  of  toxemia,  the  appetite 


256  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

is  usually  diminished.  At  other  times,  it  may  be  normal,  or 
even  above  normal.  The  appetite  is  very  important  in  tubercu- 
losis, both  because  of  its  influence  on  the  amount  of  food  taken 
and  upon  the  digestion  of  the  food  after  ingestion. 

During  the  entire  period  when  toxemia  is  present  and  during 
the  periods  marked  by  the  depressive  emotional  states  that  ac- 
company or  occur  during  the  disease,  the  appetite  is  usually 
very  seriously  lessened.  At  times,  it  is  impossible  for  the  pa- 
tient to  eat  sufficient  food  to  nourish  him.  Owing  to  the  lack 
of  appetite,  mastication  of  food,  which  is  so  essential  to  the 
proper  division  of  the  particles  and  also  to  its  insalivation,  is  im- 
perfectly carried  on.  Often  it  is  necessary  that  the  great  bulk 
of  the  food  eaten  be  of  such  a  nature  that  it  can  be  swallowed 
rather  than  chewed.  The  result  of  this  is  that  an  extra  burden 
is  thrown  upon  the  gastric  and  intestinal  functions.  While  nor- 
mal gastric  juice  is  able  to  take  care  of  protein  food,  whether 
it  be  coarsely  or  finely  divided ;  yet  a  lack  of  proper  insalivation, 
particularly  of  the  starchy  food,  has  a  very  important  inhibi- 
tory action  upon  gastric  digestion. 

Maxwell3  shows  experimentally  that  substances  in  suspen- 
sion or  in  colloidal  solution  have  the  power .  of  absorbing 
enzymes,  thereby  inhibiting  their  activity.  He  has  also  shown 
experimentally  that  unboiled  starch  administered  in  intact  grains 
does  not  hinder  the  action  of  pepsin;  but  when  starch  has 
been  boiled  and  left  in  colloidal  form,  it  seriously  inter- 
feres with  digestion  by  the  absorption  of  the  proteolytic  enzyme. 
Thus,  the  time  interval  for  the  peptic  digestion  may  be  in- 
creased fourfold  in  the  presence  of  a  2  per  cent  starch  solution. 

From  this  the  conclusion  is  drawn  that  all  cooked  farinaceous 
foods,  such  as  rice,  sago,  potato,  bread,  and  oatmeal,  interfere 
with  peptic  digestion  unless  they  are  thoroughly  insalivated. 
This  work  emphasizes  the  importance  of  chewing  farinaceous  food 
thoroughly.  Salivary,  gastric,  and  intestinal  digestion  are  more 
or  less  closely  related;  yet  each  has  its  own  particular  function 
and,  unless  carried  on  properly,  interferes  with,  or  throws  an  ex- 
tra burden  upon  the  process  next  lower. 


8The  Relation  of  Salivary  to  Gastric  Secretion.  Biochemical  Journal,  1915,  vol.  ix,  p.  323; 
quoted  editorially  in  the  Journal  of  the  American  Medical  Association,  vol.  Ixvi,  March 
4,  1916. 


GASTRIC  DISTURBANCES  IN  TUBERCULOSIS  257 

Disturbance  on  the  Part  of  the  Stomach. — Our  idea  of  the 
stomach  and  its  importance  as  an  organ  of  digestion  is  very  dif- 
ferent from  what  it  was  a  few  years  ago.  We  cannot  lose  sight 
of  the  fact  that  it  may  show  many  disturbances  in  function,  due 
to  action  outside  of  itself.  While  the  stomach  may  be  looked 
upon  as  a  reservoir  for  food,  retaining  it  until  it  is  ready  to  be 
passed  on  into  the  intestine ;  yet  certain  important  changes  take 
place  in  the  food  during  its  stay  in  this  reservoir  which  are 
preparatory  to  further  digestion;  and  it  is  necessary  that  this  or- 
gan have  proper  secretory  and  motor  power  if  normal  relation- 
ships are  to  be  maintained  in  the  remaining  portion  of  the  diges- 
tive canal. 

The  importance  of  the  quality  of  the  gastric  contents  as  dis- 
charged into  the  duodenum  cannot  be  overestimated  if  our  newer 
theories  of  secretory  and  motor  control  of  the  gastrointestinal 
tract  are  to  be  held. 

The  hormone  theory  as  it  affects  digestion  presupposes  a  nerve 
stimulus  awakened  by  the  smell,  taste,  and  intake  of  food. 
Through  this  the  gastric  hormone  is  set  free  into  the  blood  and 
finds  its  way  to  the  secretory  glands  of  the  gastric  mucosa  and 
stimulates  them  to  the  production  of  gastric  juice.  When  the 
acid  gastric  contents  are  discharged  into  the  duodenum,  they 
stimulate  the  formation  of  another  hormone,  which  passes  into 
the  blood  and  in  its  circulation  exercises  its  selective  action  upon 
the  secretory  glands  of  the  intestinal  wall,  pancreas  and  liver, 
setting  free  the  digestive  ferments  of  these  various  organs. 
Henry  Harrower4  has  discussed  this  matter  in  a  monograph 
well  worthy  of  perusal.  The  hormone  theory,  like  all  other 
contributions  which  have  added  to  our  knowledge  of  the 
function  of  the  gastrointestinal  tract,  and  which  have  pointed  the 
way  to  a  better  understanding  of  the  nervous  derangements  which 
are  found  in  our  every  day  practice,  emphasizes  the  fact  that 
disturbances  of  digestion  cannot  be  considered  as  belonging  to 
any  one  portion  of  the  tract  alone,  but  to  it  as  a  whole. 

We  must  still  recognize  the  alterations  which  occur  in  the 
gastric  secretion  because  they  are  very  important  in  their  bear- 
ing upon  further  digestion.     If  we  have  abnormal  secretion  in 


4Practical  Hormone  Therapy,   Bailliere,   Tindall   and   Cox,   London,   1914. 


258  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

the  stomach  in  tuberculosis,  we  are  apt  to  have  abnormal  secre- 
tion in  other  parts  of  the  gastrointestinal  tract  from  the  same 
cause;  abnormal  motility,  also;  because  the  motor  function  of  the 
intestinal  canal  depends  on  the  stimulus  received  from  the  acid 
contents  of  the  stomach.  In  early  tuberculosis  increased  acidity, 
probably  of  reflex  origin,  is  quite  common.  A  general,  increased 
tone  is  present  affecting  all  of  the  vagus  branches  as  suggested 
by  Eppinger  and  Hess.5  During  the  late  stage  of  the  disease, 
especially  when  toxemia  is  marked,  a  deficiency  in  hydrochloric 
acid  is  the  rule,  although  this  condition  often  alternates  with  nor- 
mal amounts  of  acid,  or  with  a  hyperacidity.  The  relaxed  con- 
ditions produced  by  toxemia  and  its  action  upon  the  sympa- 
thetics  and  by  the  general  degeneration  present,  contrary  to 
what  we  might  think,  are  not  always  accompanied  by  a  deficiency 
of  hydrochloric  acid.  Not  infrequently  do  we  find  a  hypersecre- 
tion during  these  periods.  This  can  be  explained  on  the  ground 
that  the  reflex  stimulation  of  the  vagus  is  stronger  than  the  com- 
bined reflex  and  central  stimulation  of  the  sympathetics.  Inas- 
much as  control  of  the  pylorus  depends  to  a  considerable  extent 
upon  the  acidity  of  the  secretion,  as  it  passes  from  the  stomach 
into  the  duodenum,  we  must  recognize  the  importance  of  the  qual- 
ity of  the  gastric  juice  because  of  its  effect  on  the  entire  canal. 

At  times  we  see,  especially  in  the  later  stages,  a  decided  in- 
crease in  the  amount  of  secretion  which  remains  in  the  fasting 
organ.  This  may  have  either  a  normal,  a  deficient,  or  an  in- 
creased percentage  of  acid.  This  condition  is  often  accompanied 
by  more  or  less  troublesome  symptoms.  It  seems  to  be  associated 
often  with  atony  and  dilatation. 

Atony  and  dilatation  of  the  stomach  are  usually  associated  with 
a  downward  displacement  of  the  organ.  This  dilatation  may  be 
due  to  errors  in  diet,  overfeeding,  altered  secretion  accompanied 
by  abnormal  gas  formation,  obstruction  of  the  pylorus,  or  to  a 
general  degeneration  of  the  cells  of  the  wall  of  the  organ  (I  have 
seen  cases  postmortem  where  the  stomach  was  dilated  to  such  an 
extent  that  its  capacity  was  three  or  four  times  its  normal). 
Hypochlorhydria  is  often  found  in  tuberculosis  in  patients  in 


6Die   Vagotonic,    Sammlung,    Klinischer   Abhandlungen,    von    Noorden,    Heft.    9    u.    10, 
Berlin,  1910. 


HYPOCHLORHYDRIA  259 

whom  there  is  a  generally  decreased  vagus  tonus.  In  such,  and 
usually  in  others,  there  is  a  deficiency  of  acid  during  times  of 
acute  toxemia  owing  to  the  fact  that  the  toxins  stimulate  the 
sympathetics  centrally  and  inhibit  the  gastric  secretion. 

Hypochlorhydria. — There  is  a  certain  class  of  individuals  who 
naturally  have  slow  digestion.  It  would  be  manifestly  erroneous 
to  expect  the  spare  asthenic  to  digest  as  rapidly  and  as  well  as 
the  sthenic  or  hypersthenic  individual.  When  those  of  the  hypo- 
sthenic  and  asthenic  type  develop  tuberculosis  the  question  of 
nutrition  usually  becomes  a  more  serious  problem  than  it  does 
in  the  stronger  individuals.  The  toxemia  of  tuberculosis,  added 
to  the  already  slow  digestion  makes  a  serious  complication. 

Since  toxemia  and  states  of  anxiety,  disappointment,  and  dis- 
couragement, as  well  as  painful  conditions  when  present,  stimu- 
late the  sympathetics  and  cause  a  general  inhibition  both  in  the 
seeretory  and  motor  functions  of  the  entire  gastrointestinal 
canal,  it  can  be  seen  that  these  have  a  tendency  to  retard  diges- 
tion and  produce  disturbed  motility,  with  stasis  of  the  bowel 
contents.  This  is  again  followed  by  absorption  of  poisons  from 
the  alimentary  canal  which  further  depresses  the  digestive  func- 
tions. The  effect  of  these  factors  is  greater  upon  those  with  nat- 
urally slow  digestive  function  than  upon  those  with  function  nor- 
mal or  above  normal. 

When  suffering  from  hypochlorhydria,  if  only  temporary,  it 
is  well  to  urge  patients  not  to  eat  large  quantities  of  food  until 
this  condition  is  corrected.  The  best  foods  under  these  circum- 
stances are  those  which  have  rather  a  stimulating  effect  on  the 
gastrointestinal  tract.  Meat  extracts,  strong  consomme,  meat 
itself  and  dry  toast,  well  chewed,  stimulate  secretion.  Dilute 
hydrochloric  acid,  5  to  10  drops  taken  after  meals  is  of  consider- 
able value.  The  following  prescriptions  I  have  used  to  ad- 
vantage : 

F*     Acid  hydrochlor  dilut  25.00 

Glycerin  25.00 

Pepsin  scales  50.00 

Aq.  dest.  q.  s.  ad.  100 

M. 
Sig.:     1  to  2  teaspoonfuls  in  water  one-half  hour  after  meals. 


260  DIGESTIVE   SYSTEM  IN   TUBERCULOSIS 

I£     Tinct.  nux  vom.  12.00 

Tinet.  cinchon,  q.  s.  ad.  100.00 

M. 
Sig.:    One  teaspoonful  in  water  20  minutes  before  meals. 

On  the  other  hand,  if  the  deficiency  is  chronic,  then  the  patient 
must  be  fed  liberally,  using  a  diet  which  will  stimulate  secretion 
and  favor  regularity  of  bowel  movement.  At  the  same  time,  hy- 
drochloric acid  should  be  administered.  General  measures  for 
improving  the  patient's  metabolism  are  of  the  greatest  impor- 
tance. 

Hyperchlorhydria. — Hyperchlorhydria,  contrary  to  the  gen- 
eral belief,  is  quite  common  in  pulmonary  tuberculosis.  As  Ep- 
pinger  and  Hess  have  well  pointed  out,  there  is  a  large  class  of 
individuals  which  may  be  said  to  have  naturally  an  increased 
vagus  tone.  The  vagus  nerve  is  the  nerve  which  presides  over 
secretion  and  motility  for  the  gastrointestinal  canal ;  consequent- 
ly the  vagotonic  would  naturally  have  an  ample  acid  secretion. 
Those  who  are  not  vagotonic  naturally  could  be  rendered  so  by 
stimulation  of  the  vagus  alone;  or  by  stimulating  both  vagus 
and  sympathetic  systems,  but  in  such  a  manner  that  the  vagus 
stimulation  predominates  over  the  sympathetic. 

During  toxemia  in  pulmonary  tuberculosis,  as  previously  men- 
tioned, the  sympathetic  system  is  stimulated  centrally  by  the 
toxins  and  peripherally  by  the  inflammation  in  the  lung  and 
adrenin  which  is  increased  by  the  central  sympathetic  stimula- 
tion; and,  the  vagus  is  stimulated  peripherally.  As  a  result  of 
this,  sympathetic  stimulation  is  nearly  always  predominant  during 
toxemia,  at  least  to  a  certain  extent.  As  soon  as  the  acuteness 
of  the  toxemia  passes  away,  and  the  central  stimulation  of  the 
sympathetics  lessens  or  ceases,  then  in  the  great  majority  of 
cases  of  tuberculosis,  the  patient  passes  into  a  condition  of  rela- 
tively increased  vagus  tonus.  His  appetite  improves  and  his 
digestive  powers  are  even  above  normal.  A  state  of  hyperchlor- 
hydria often  exists  under  these  conditions.  As  a  rule  it  is  not 
sufficient  to  cause  discomfort;  at  other  times  it  is  necessary  to 
afford  relief  to  the  patient.  Sometimes  hypersecretion  only  is 
present  without  an  increase  in  the  amount  of  acid. 

Increased  acidity  is  often  accompanied  by  a  stasis  of  the  in- 


HYPERCHLORHYDRIA  261 

testinal  contents  and  a  spastic  constipation,  both  symptoms  being 
due  to  increased  vagus  tone.  The  explanation  of  this  condition  is 
that  the  peripheral  stimulation  of  the  vagus  by  the  inflammation 
in  the  lung  results  as  a  rule  in  the  vagus  impulse  being  stronger 
than  the  sympathetic  stimulation  and  the  conservative  forces  pre- 
dominating over  the  inhibiting  influence  of  the  sympathetics. 

In  case  of  a  marked  hyperchlorhydria  all  stimulating  food 
should  be  eliminated.  Coarse  foods  which  are  likely  to  irritate 
the  stomach  should  also  be  withheld  from  diet,  such  as  lettuce, 
tomatoes,  cabbage,  celery,  and  coarse  bread.  Foods  should  be 
confined  to  the  soft,  non-irritating  type.  The  food  should  be 
either  wholly  unseasoned  or  seasoned  very  lightly.  The  secre- 
tion of  hydrochloric  acid  can  be  depressed  somewhat  by  the  use 
of  atropin,  %00  of  a  grain  being  given  three-quarters  of  an  hour 
before  each  meal.  This  quantity,  however,  should,  at  times,  be 
increased  and  should  usually  be  pushed  to  the  point  of  dryness 
of  the  throat.  Atropin  is  particularly  effective  in  those  naturally 
vagatonic  and  where  the  condition  is  a  result  of  vagus  stimula- 
tion without  organic  lesions  such  as  that  caused  by  the  pulmon- 
ary reflex.  When  due  to  ulcer,  appendicitis,  or  disease  of  the  gall 
bladder,  it  may  be  of  limited  or  no  value.  Its  use  should  be  per- 
sisted in  for  a  prolonged  time. 

Bromides  are  also  valuable  in  these  cases.  From  10  to  30  grains 
of  bromide  of  soda  may  be  given  before  meals  although  its  ac- 
tion is  not  as  certain  as  that  of  atropin. 

A  very  important  point  in  the  treatment  of  hyperchlorhydria 
is  to  neutralize  the  acid  because  it  not  only  produces  discom- 
fort in  the  way  of  a  burning  sensation,  but,  where  we  have  large 
quantities,  it  has  a  tendency  to  produce  spasm  of  the  pylorus 
and  interfere  with  the  emptying  of  the  stomach  contents  into 
the  duodenum,  which,  if  maintained  long  enough,  will  favor  dila- 
tation. It  also  throws  a  great  burden  upon  the  intestinal  secre- 
tions to  neutralize  the  excess  of  acid  when  it  enters  the  duo- 
denum, and  thus  delays  the  emptying  of  the  stomach.  For  neu- 
tralizing the  acid  the  old  favorite  combination  of  subcarbonate 
or  subnitrate  of  bismuth,  bicarbonate  of  soda  and  carbonate  of 
magnesium,  is  excellent.  These  may  be  used  in  equal  parts  by 
weight,  one  teaspoonful  to  be  given  two  or  three  hours  after 


262  DIGESTIVE  SYSTEM  IN   TUBERCULOSIS 

meals  at  the  time  when  the  burning  begins.  The  bismuth  has  a 
tendency  to  depress  the  secretion  of  the  acid,  while  the  soda 
and  magnesium  neutralize  it.  If  the  patient  is  inclined  to  con- 
stipation the  magnesium  may  be  increased  and  the  bismuth  be 
decreased  in  amount.  If,  on  the  other  hand,  there  is  a  tendency 
to  diarrhea,  the  bismuth  may  be  increased  and  the  magnesium 
reduced ;  or,  if  this  is  not  sufficient  to  counteract  the  acidity,  more 
soda  may  be  added.  At  other  times  plain  bicarbonate  of  soda 
may  be  used  in  teaspoonful  doses. 

It  is  necessary  to  explain  to  the  patient  the  necessity  of  tak- 
ing sufficient  of  the  salts  to  neutralize  the  acid ;  otherwise  he  will 
not  understand  and  is  apt  to  take  small  amounts  and  only 
partially  neutralize  and  in  this  way  obtain  only  partial  relief. 
Sometimes  an  absolutely  meat-free  diet  persisted  in  for  a  long 
time  seems  to  help  most;  although,  at  first  the  acidity  is  worse 
because  of  the  lack  of  albumin  to  combine  with  the  acid.  I  have 
found  in  my  work  among  the  tuberculous,  however,  that  a  gen- 
eral diet  is  the  best;  and,  inasmuch  as  I  feel  that  some  proteid 
is  essential,  I  do  not  like  to  eliminate  meat  from  the  diet,  and 
usually  try  to  control  the  acidity  as  well  as  possible  without 
eliminating  it,  at  least,  until  such  time  as  the  condition  of  the 
patient  will  permit  of  more  rigid  diet  without  risk.  When  due 
to  ulcer  of  either  the  stomach  or  duodenum,  these  conditions 
must  receive  appropriate  treatment. 

Dilatation  of  the  Stomach. — There  are  many  factors  in  tuber- 
culosis which  tend  to  produce  dilatation  of  the  stomach.  Some 
of  these  are  avoidable,  others  are  not.  In  the  early  stages  of  the 
disease  it  is  not  apt  to  occur  unless  there  is  some  obstruction 
of  the  pylorus.  In  chronic  cases  it  formerly  was  often  found  as  a 
result  of  overfeeding.  It  is  in  the  late  cases,  however,  after  de- 
generative processes  have  set  in  and  the  Avails  have  become  atonic 
that  this  condition  becomes  a  serious  factor.  When  this  condi- 
tion has  been  attained  the  digestive  juices  are,  as  a  rule,  impaired ; 
the  muscles  are  weakened;  motility  is  lessened;  the  food  re- 
mains in  the  stomach  longer  than  it  should;  gases  develop,  and 
the  organ  dilates.  This  often  occurs  during  a  prolonged  period 
of  toxemia  when  the  inhibitory  influences  of  the  sympathetic 
nervous  system  are  predominant.    Again,  it  occurs  in  hyperacidity 


DILATATION   OF   THE   STOMACH  263 

when  the  spasm  of  the  pylorus  prevents  its  opening  naturally. 

Slight  degrees  of  dilatation  may  be  present  without  trouble- 
some symptoms  arising;  and  a  stomach  when  dilated  to  a  slight 
degree  may  again  become  functionally  normal.  When,  however, 
the  severe  degrees  of  dilatation  that  are  encountered  in  advanced 
tuberculosis  take  place,  in  which,  through  toxemia,  marked  de- 
generation has  become  established,  and  delayed  and  imperfect 
digestion  has  resulted,  the  symptoms  become  extremely  trouble- 
some and  are  also  difficult  to  relieve. 

Patients  suffering  from  dilatation  of  the  stomach  complain  of 
loss  of  appetite,  feeling  of  fulness,  nausea,  and  vomiting.  They 
may  think  they  will  enjoy  a  meal,  but  are  usually  satisfied  when 
they  have  eaten  a  few  mouthfuls.  They  also  have  a  feeling  of 
fulness  on  eating  small  amounts  of  food.  This  common  symp- 
tom of  dilatation — feeling  of  fulness — has  been  shown  by  Hertz 
and  his  co-workers6  to  be  due  to  tension  exerted  on  the  circular 
muscle  fibers  of  the  stomach.  Changes  in  the  circular  muscles 
are  brought  about  by  a  reflex  from  the  esophagus  during  the  act 
of  swallowing.  When  food  passes  through  the  esophagus  it  re- 
flexly  stimulates  the  circular  muscles  of  the  stomach  to  dilate 
and  make  room  for  the  additional  food  which  enters.  If  food  is 
eaten  rapidly  and  sufficient  time  is  not  allowed  for  the  circular 
coat  to  dilate,  a  feeling  of  fulness  results;  or,  if  the  stomach  is  al- 
ready completely  relaxed,  as  it  is  in  cases  of  marked  dilatation, 
then  the  taking  of  food  stimulates  the  fibers  to  further  relaxa- 
tion, just  the  same  as  in  the  non-dilated  organ;  but,  inasmuch  as 
the  circular  muscular  coat  is  already  fully  relaxed,  further  re- 
sponse to  the  esophageal  swallowing  reflex  cannot  do  more  than 
to  attempt  to  relax  an  already  relaxed  muscle.  The  result,  how- 
ever, is  the  same  feeling  of  fulness,  as  is  noted  when  the  organ 
is  fully  distended  by  food;  because  the  circular  fibers  are  sub- 
jected to  increased  tension  after  they  are  fully  relaxed. 

I  have  found  it  best,  if  this  condition  is  severe,  to  feed  the 
patient  at  frequent  intervals;  to  reduce  the  amount  of  liquid 
taken  with  the  meals  to  the  minimum;  and,  above  all  else,  to 
withhold  from  the  diet  food  which  is  slow  of  digestion  as  well  as 
such  articles  as  produce  gas.    However,  if  the  dilatation  is  not  too 


6The  Sensibility  of  the  Alimentary  Canal,  Oxford  University  Press,  London,  1911. 


264  DIGESTIVE   SYSTEM  IN   TUBERCULOSIS 

severe  and  not  causing  too  much  disturbance  a  liberal  diet  should 
be  insisted  upon,  for  the  condition  can  only  hope  to  be  improved 
as  the  general  health  of  the  patient  improves.  Concentrated  nu- 
tritious food  should  make  up  an  important  part  of  such  a  dietary. 
Lavage  is  sometimes  valuable  in  these  cases.  Strychnine  seems  to 
offer  some  aid;  but  building  up  the  patient  where  this  is  pos- 
sible, is  of  greatest  importance.  Unlike  dilatation  in  the  in- 
dividual who  is  otherwise  strong  and  healthy,  we  here  have  mal- 
nutrition and  general  lack  of  tone  as  a  more  important  factor 
than  obstruction. 

Disturbance  on  the  Part  of  the  Intestines. — Many  of  the  non- 
tuberculous  complications  on  the  part  of  the  intestinal  tract  are 
also  extremely  common  in  tuberculosis. 

Enterocolitis. — This  complication  is  a  very  common  one.  It 
may  be  of  slight  degree  or  it  may  be  very  severe.  It  may  be  due 
to  errors  in  diet,  or  result  from  an  obstinate  constipation  and  the 
use  of  laxatives  to  which  so  many  people  are  addicted ;  or,  in  tu- 
berculosis, it  is  probably  at  times  due  to  toxemia;  and,  at  times, 
to  a  venous  congestion  in  the  intestinal  wall,  the  latter  being  a 
constant  factor  of  this  disease.  The  excessive  use  of  raw  eggs 
will  produce  it. 

According  to  the  severity  of  the  case  these  patients  complain 
of  loss  of  appetite,  nausea,  feeling  of  fulness  and  sometimes 
distension  of  the  entire  abdomen,  accompanied  quite  often  by 
colicky  pains.  Flatulence,  general  lassitude,  nervous  irritabil- 
ity and  sometimes  depression  are  common.  The  entire  course 
of  the  colon  may  be  sensitive  to  pressure.  The  inflammation 
usually  involves  both  the  large  and  small  intestine.  Constipa- 
tion may  be  present;  but,  if  so,  it  is  apt  to  alternate  with  loose 
movements  or  diarrhea.  The  patient  usually  passes  one  or  two 
soft  stools  a  day  and  has  considerable  gas.  These  patients  may 
usually  be  relieved  by  proper  treatment  although  we  may  never 
be  sure  that  we  have  arrived  at  a  permanent  cure,  for  relapses 
are  extremely  common.  Treatment  depends  upon  the  severity 
of  the  case. 

The  most  important  measures  in  the  treatment  of  this  com- 
plication are  the  relief  of  mental  depression,  rest  and  diet.  It 
is  well  for  the  patient  to  understand  that  the  maintenance  of  a 


ENTEROCOLITIS  265 

good  result  depends  not  on  medicines  but  on  persistently  fol- 
lowing rational  living  and  appropriate  diet.  Remembering  the 
effect  of  emotions  on  the  digestive  tract,  the  importance  of  op- 
timism cannot  be  overestimated.  If  the  condition  is  at  all  severe, 
rest  in  bed  is  essential  for  the  proper  handling  of  this  compli- 
cation. 

In  severe  cases  I  put  the  patient  to  bed  and  eliminate  all 
questionable  foods  from  the  diet.  At  first,  nothing  but  gruel 
and  milk  or  gruel  and  buttermilk  are  given,  making  the  gruel 
by  boiling  rice  or  barley  until  it  becomes  a  pulp,  and  straining 
this  through  a  cloth.  Water  is  then  added  to  make  it  the  con- 
sistency of  thick  soup.  A  glass  of  gruel  and  a  glass  of  milk  or 
buttermilk  is  given  three  or  four  times  a  day.  In  some  instances 
milk  will  not  be  tolerated.  Then  gruels  and  soups  may  be  used 
exclusively.  In  some  cases  this  line  of  treatment  proves  wholly 
inadequate.  Under  such  conditions  we  should  recall  the  pos- 
sibility that  the  colloidal  boiled  starch  may  be  interfering  with 
the  peptic  digestion.  Sometimes  it  is  best  to  eliminate  starch 
wholly  from  the  dietary. 

Colonic  injections  of  starch  water  and  bismuth  are  help- 
ful. Starch  water  is  made  by  boiling  the  starch  and  adding 
water  so  that  it  is  of  such  consistency  that  it  passes  through  the 
syringe  easily.  To  each  quart  of  starch  water  one  dram  of  sub- 
nitrate  of  bismuth  is  added.  This  is  used  quite  warm.  It  is  in- 
jected into  the  rectum  slowly  and  the  patient  is  instructed  to 
retain  it  at  least  for  half  an  hour,  or  even  longer,  if  possible. 
This  is  given  once  or  twice  a  day  at  first;  and,  as  the  patient 
improves,  the  intervals  are  lengthened.  Hot  packs  to  the  ab- 
domen for  two  hours  once  a  day  or  one  hour  twice  a  day  are 
employed.  As  medication  the  patient  is  usually  given  a  tea- 
spoonful  of  castor  oil  each  night.  This  method  has  proved  very 
satisfactory  in  handling  these  patients. 

Now  that  we  fully  understand  the  antiperistaltic  movement 
of  the  colon  we  recognize  that  it  is  not  necessary  to  use  high 
flushings,  as  we  formerly  did,  because  fluids  thrown  into  the 
rectum  will  soon  travel  the  entire  course  of  the  colon ;  and  even 
through  the  ileocecal  valve  if  patulous.  Sometimes  patients 
will  complain  that  they  cannot  take  large  enemas  without  feel- 


266  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

ing  ill.  They  have  feelings  of  faintness,  colicky  pains,  and 
nausea  owing  to  irritation  of  vagus  endings. 

The  following  diet  has  proved  very  satisfactory  in  the  treat- 
ment of  the  majority  of  patients  having  entercolitis. 

Diet  Permitted  in  Severe  Cases. — At  first,  gruel  (rice  or  bar- 
ley), milk  (diluted  with  half  water  or  Vichy)  or  buttermilk;  or 
gruel  soups  where  milk  is  not  tolerated. 

As  the  patient  improves,  the  following  are  permitted.  Rice, 
toast,  or  stale  bread,  cereals,  soups,  sago,  noodles,  macaroni, 
baked  or  mashed  potato,  eggs,  either  raw,  soft  boiled,  or  poached. 

Moderately  Severe  Cases. — These  cases  may  have  all  of  the  above, 
and  in  addition  such  light  vegetables  as  spinach,  carrots,  cauli- 
flower, peas,  and  squash;  and  meats  sparingly. 

Mild  Cases. — These  cases  may  have  the  above  with  whole  wheat 
bread,  meats,  fish,  and  fruit  sauces. 

In  colitis  it  is  always  best  to  take  foods  warm  and  avoid  such 
cold  foods  as  ice  cream,  cold  milk,  and  cold  water.  Hot  water 
may  be  taken  to  advantage. 

If  a  more  laxative  diet  is  required  prunes,  oatmeal,  and  honey 
may  be  added. 

Foods  Forbidden. — Coffee  (especially  strong),  all  acid  or  raw 
fruits,  legumes,  cheese,  cabbage,  smoked  meat  and  fish,  fat  meat, 
pork,  veal,  fresh  bread,  and  pastry.  In  cases  accompanied  by 
severe  diarrhea,  all  extracts  of  meat  should  be  withheld  from 
the  diet  until  acute  symptoms  have  disappeared. 

Intestinal  Stasis. — The  mechanical  factors  of  digestion  have 
assumed  a  much  more  important  place  in  medical  literature  in 
recent  years  than  formerly.  In  America  this  has  been  largely 
through  the  splendid  work  of  W.  B.  Cannon.7  We  were  for- 
merly accustomed  to  speak  only  of  the  peristaltic  action  of  the 
small  intestine,  but  we  now  know  that  there  is  a  definite  peri- 
staltic action  of  the  stomach  and  of  the  large  bowel.  In  tuber- 
culosis stasis  is  extremely  common.  The  peristaltic  movements 
of  the  intestines  are  increased  by  the  vagus  and  inhibited  by  the 
splanchnics,  both  of  which  are  stimulated  in  tuberculosis,  re- 
sulting now  in  spastic  constipation  and  again  in  that  of  the 


7The  Mechanical  Factors  of  Digestion,   Longmans  Green  &  Co.,   New  York,   1911;   also 
Bodily  Changes  in  Pain,  Hunger,  Fear,  and  Rage,  D.  Appleton  and  Co.,  New  York,  1915. 


INTESTINAL  STASIS  267 

atonic  type.  Inasmuch,  as  congestion  of  the  intestinal  veins  is 
present  to  a  greater  or  lesser  extent  in  all  pulmonary  inflam- 
mations, we  have  interference  with  the  action  of  the  peristaltic 
wave  from  this  cause,  even  in  early  cases;  while  we  have  the 
marked  toxemia  and  degeneration  added  later. 

There  are  several  points  in  the  alimentary  tract  where  food 
is  naturally  hindered  in  its  downward  progress.  The  normal 
passage  of  food  should  require  somewhere  in  the  neighborhood 
of  twenty-four  hours  in  passing  from  the  stomach  to  the  rec- 
tum. The  first  point  of  delay  is  that  of  the  pylorus,  which  is 
presided  over  by  certain  reflexes  which  depend  primarily  on  the 
acid  content  of  the  stomach,  and,  secondarily,  upon  the  neu- 
tralization of  these  acid  contents  after  they  pass  into  the  duo- 
denum. In  case  of  an  increased  acidity  in  the  stomach  we  have 
a  reflex  spasm  of  the  sphincter  which  retards  emptying  and  often- 
times leads  to  more  or  less  dilatation  of  the  organ.  The  pylorus 
may  be  kept  closed  reflexly  by  inflammations  in  the  neighbor- 
ing organs.  This  is  particularly  evident  at  times  in  cases  of 
appendicitis,  duodenal  ulcer,  and  cholecystitis. 

The  next  point  is  that  of  the  ileocecal  valve.  The  purpose  of 
the  closure  of  the  ileocecal  valve  is  probably  to  favor  absorption. 
Food  naturally  requires  about  four  or  five  hours  in  passing  from 
the  stomach  to  the  ileocecal  valve.  When  such  irritations  as 
those  resulting  from  cholecystitis,  chronic  appendicitis  or  tu- 
berculosis of  the  appendix,  or  inflammatory  conditions  about 
the  head  of  the  cecum,  are  present,  the  opening  of  the  sphincter 
may  be  interfered  with  and  stasis  in  the  ileum  result.  The 
same  is  due  at  times,  and  probably  more  often,  to  mechanical 
obstruction.  Normally,  when  food  enters  the  stomach,  the  ileo- 
cecal valve  is  reflexly  opened;  but  any  irritation  in  the  neigh- 
borhood of  the  valve  itself  may  prevent  this  opening  and  favor 
stasis.  The  cecum  and  ascending  colon  is  a  sort  of  churning 
place  for  the  food.  Like  the  stomach  this  is  another  reservoir 
where  it  is  retained  for  a  considerable  period  of  time. 

The  passage  of  food  along  the  colon  is  very  different  from 
that  in  the  small  intestine.  Here,  instead  of  being  pushed  along 
by  the  small  peristaltic  waves,  such  as  are  present  in  the  small 
intestine,  the  particles  of  food  are  carried  onward  more  or  less 


268  DIGESTIVE  SYSTEM  IN   TUBERCULOSIS 

en  masse  by  massive  peristaltic  waves  and  collect  in  certain 
portions  such  as  the  middle  of  the  transverse  colon,  the  pelvic 
colon,  and  the  rectum. 

With  both  the  central  and  peripheral  stimulation  of  the  sym- 
pathetica, the  peripheral  stimulation  of  the  vagus,  the  venous 
congestion  of  the  intestines,  the  degeneration  in  the  walls  of 
the  gut,  the  displacements  such  as  are  common  in  tuberculosis, 
particularly  after  the  stage  of  wasting  has  been  reached,  stasis 
in  both  the  ileum  and  colon  become  exceedingly  common  and 
also  become  matters  of  extreme  importance. 

The  ill  effects  of  stasis  upon  the  patient  are  mainly  due  to 
absorption  of  poisonous  materials  which  generate  during  the 
slow  passage  of  the  contents  in  the  bowel  which  act  upon  the 
brain  centers  producing  general  instability  of  function.  Not 
only  do  we  have  the  general  effects  of  the  absorption  of  these 
deleterious  products  to  deal  with,  but  we  have  a  disturbance  in 
the  rhythmical  function  of  the  gastrointestinal  tract.  These  pa- 
tients suffer  from  toxemia,  which  is  expressed  in  the  symptom- 
complex:  headache,  malaise,  aching  more  or  less  severe  through- 
out various  portions  of  the  body,  rapid  heart  action,  alteration 
and  depression  of  appetite,  and  general  inhibition  of  the  gastro- 
intestinal functions,  which  results  at  times  in  marked  dis- 
turbance of  nutrition.  Often  flatulence  and  colicky  pains  are 
troublesome.  This  toxemia  is  often  preceded  by  a  retardation  of 
the  intestinal  contents  due  to  stimulation  of  the  vagus.  Studies 
in  visceral  neurology,  as  well  as  clinical  observation,  lead  me 
to  believe  that,  omitting  cases  of  definite  obstruction,  increased 
tonus  of  the  intestinal  branches  of  the  vagus  is  the  most  fre- 
quent underlying  cause  of  intestinal  stasis. 

The  relief  of  stasis  is  not  a  simple  matter  because  patients 
who  suffer  from  it,  even  those  without  tuberculosis,  suffer  more 
or  less  from  a  disturbed  nerve  equilibrium.  It  is  important 
not  only  to  correct  the  stasis  for  the  time  being,  but  to  keep 
it  corrected ;  to  improve  the  habits  of  the  individual ;  and  to  re- 
educate the  nervous  system.  Inasmuch  as  this  is  a  part  of  the 
general  treatment  of  tuberculosis  anyway,  these  patients  should 
improve  by  the  general  methods  which  are  employed  in  the 
handling  of  this  disease. 


INTESTINAL  STASIS  269 

Stasis  cannot  be  cured  by  cathartics.  It  is  important  to  try 
in  every  way  possible  to  obtain  the  normal  onward  movement 
of  the  material  in  the  gastrointestinal  canal.  It  is  very  dif- 
ficult to  discuss  this  question  aside  from  constipation,  although 
the  two  are  not  identical.  Such  measures  should  be  utilized 
as  favor  a  normal  passage  of  the  food  in  the  intestine,  because 
by  so  doing  the  decomposition  and  fermentation  which  other- 
wise take  place  are  prevented  and  the  ill  effects  of  absorption 
are  avoided.  Aside  from  this,  the  production  of  gases  which 
are  more  or  less  harmful  in  these  cases  in  that  they  produce 
dilatation  and  also  stimulate  to  irregular  contractions  and  the 
production  of  colicky  pain,  may  be  avoided.  Bran,  agar-agar, 
and  paraffin  oil  are  all  valuable  in  the  treatment  of  these  cases. 
Hot  applications  to  the  abdomen  have  a  splendid  effect  in  re- 
laxing the  spasm  which  may  be  produced  by  the  irritating 
gases.  Sometimes  a  course  of  some  of  the  mineral  waters,  while 
theoretically  contraindicated,  is  allowable  for  it  seems  almost 
necessary  to  administer  some  direct  relief.  We  are  obliged  to 
deal  somewhat  differently  with  the  tuberculous,  with  his  toxemia 
and  degeneration,  from  what  we  do  with  the  non-tuberculous. 
Such  waters  as  Hunyadi  Janos,  Apenta,  and  many  that  we 
have  in  our  own  country,  such  as  Pluto  and  Abilena,  may  be 
used.  The  use  of  these  should  only  be  temporary  and  with- 
drawn after  serving  their  purpose.  These  patients  should  be 
encouraged  to  drink  large  quantities  of  plain  water,  particu- 
larly warm  water.  Atropin  should  be  used  freely  and  persist- 
ently. 

Constipation. — There  are  many  factors  in  tuberculosis  which 
tend  to  the  production  of  constipation  or  to  the  aggravating  of 
such  a  condition  when  it  already  exists.     These  are: 

1.  The  habits  of  previous  years  which  have  so  often  caused 
neglect  of  this  important  function  of  the  bowels. 

2.  Faulty  habits  of  eating  which  are  more  or  less  compen- 
sated for  as  long  as  the  patient  is  well,  but  which  are  magni- 
fied by  illness. 

3.  Disturbances  of  the  normal  physiologic  rhythm  of  the 
gastrointestinal  function,  whether  due  to  motor  or  sensory 
change  or  alteration  in  position  or  contour  of  organs. 


270  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

4.  The  toxic  and  reflex  influences  through  the  sympathetic 
and  vagus  nerves  and  the  degenerations  which  are  essentially 
due  to  the  tuberculous  process. 

5.  The  splanchnic  congestion  which  is  produced  by  the  dis- 
turbance in  the  function  of  the  respiratory  muscles  and  the  con- 
sequent reduction  and  limitation  of  the  inspiratory  act,  as  de- 
scribed more  fully  on  page  301. 

6.  The  limitation  of  exercise  made  necessary  by  the  activ- 
ity in  the  tuberculous  focus. 

7.  The  eating  of  concentrated  foods  to  the  exclusion  of  those 
of  the  more  bulky  type,  partly  from  former  habit,  partly  be- 
cause of  the  misguided  notion  that  concentrated  foods  are  the 
only  ones  of  value  in  tuberculosis,  and  partly  because  a  dis- 
turbed appetite  and  repugnance  for  food  make  it  difficult  if  not 
impossible  to  chew  the  food  of  a  more  bulky  nature. 

I  have  found  in  my  own  work  that  the  classification  of  con- 
stipation into  atonic  and  spastic,  as  suggested  by  Cohnheim,8  is 
a  very  practical  one  from  the  standpoint  of  therapy.  We  find 
more  or  less  constipation  in  a  very  large  per  cent  of  our  cases. 
In  some  it  is  of  the  atonic  type,  in  others  of  the  spastic  type,  and 
more  generally,  a  combination  of  the  two.  The  treatment  of 
these  two  types  is  radically  different,  consequently  difficulties 
arise,  particularly  in  the  mixed  type. 

Hertz9  also  recognizes  two  types  of  constipation  differing  some- 
what from  Cohnheim.    He  says: 

"As  a  result  of  my  investigations  with  the  x-rays  on  the 
motor  functions  of  the  intestines  in  health  and  disease,  I  con- 
cluded that  all  cases  of  constipation  can  be  divided  into  two 
classes:  in  the  first,  which  may  be  called  intestinal  constipa- 
tion, the  passage  through  the  intestines  is  delayed,  whilst  defe- 
cation is  normal;  in  the  second  class,  for  which  I  have  adopted 
the  term  dyschezia,  there  is  no  delay  in  the  arrival  of  the 
feces  in  the  pelvic  colon,  but  their  final  expulsion  is  not  ade- 
quately performed." 

Of  these  two  types  of  constipation  it  can  readily  be  seen 
that,   that  of  the   spastic  type  or  intestinal  type   of  Hertz  is 


8Disturbances  of  the  Digestive  Canal,  Translated  by  Fulton,  J.  B.  Dippincott  Co.,  1909. 
sThe  Sensibility  of  the  Alimentary  Canal,  Oxford  University  Press,  1911. 


CONSTIPATION  271 

more  serious  than  the  atonic,  because  the  contents  are  delayed 
in  the  passages  higher  up  in  the  canal  where  the  absorptive 
powers  of  the  gut  are  greater  and  at  a  time  when  decomposi- 
tion of  the  contents  is  more  apt  to  occur.  Consequently 
spastic  or  intestinal  constipation  is  accompanied  by  greater 
toxemia.  It  is  also  accompanied  by  the  formation  of  gas  and 
sooner  or  later  leads  to  destructive  changes  in  the  wall  of  that 
portion  of  the  bowel  affected.  The  patient  suffering  from  atonic 
constipation,  on  the  other  hand,  does  not  suffer  from  toxemia 
to  so  great  an  extent  neither  does  he  experience  the  deleterious 
effect  of  gas  in  the  bowel. 

Atonic  Constipation. — Atonic  constipation  is  that  type  in 
which  the  bowel  itself  seems  to  have  lost  its  natural  response  to 
stimulation.  This  type  of  constipation  is  usually  characterized 
by  a  large  dry  stool.  In  this  form  of  constipation  gas  is  not 
a  prominent  symptom,  in  fact  it  is  often  entirely  absent.  Of- 
ten the  only  complaint  of  the  patient  is  the  inability  to  have  a 
normal  stool.  Sometimes,  however,  they  have  toxic  symptoms 
as  feelings  of  dullness,  headache,  malaise,  and  the  lack  of  de- 
sire for  work.  These  patients  are  in  the  habit  of  relieving 
themselves  either  by  the  use  of  enemas  or  laxatives,  both  of 
which  answer  the  purpose  for  the  time,  but  in  the  end  prove 
harmful.  One  measure  of  great  importance  in  the  treatment, 
particularly  of  this  form  of  constipation,  is  somewhat  difficult 
to  carry  out  in  tuberculosis, — that  of  exercise.  Exercise  is  valu- 
able; but  we  are  forced  in  treating  tuberculosis,  particularly 
during  the  active  stage,  to  keep  the  patient  quiet.  The  wasting 
which  occurs  in  advanced  cases  and  the  congestion  of  the  in- 
testinal tract  have  a  tendency  to  increase  constipation  when 
present,  no  matter  whether  it  be  of  the  atonic  or  spastic  type. 

The  first  thing  in  the  treatment  of  all  forms  of  constipation 
is  to  get  away  from  cathartics.  In  fact,  they  of  themselves 
will  eventually  aggravate  the  very  condition  which  we  are  try- 
ing to  eliminate. 

Atonic  constipation  requires  that  type  of  food  which  fur- 
nishes large  amounts  of  waste  matter.  It  should  be  rich  in 
cellulose  and  of  such  a  character  as  will  mechanically  stimulate 
the  mucous  membrane. 


272  DIGESTIVE   SYSTEM   IN   TUBERCULOSIS 

It  is  my  custom  to  have  these  patients  drink  one  or  two 
glasses  of  cold  water  on  going  to  bed  and  also  the  same  on 
getting  up  in  the  morning.  Fruit  juices  such  as  lemonade  and 
orange  juice  may  be  used  in  the  morning  before  breakfast  to  ad- 
vantage. Tea  and  coffee  should  be  used  sparingly  or  not  at 
all.  Buttermilk,  at  least  two  days  old,  may  be  used.  Butter 
should  be  used  freely.  Nearly  all  kinds  of  fruit  are  allow- 
able in  this  form  of  constipation.  Vegetables  of  the  coarser 
varieties,  such  as  lettuce,  celery,  asparagus,  string  beans,  spin- 
ach, legumes,  and  tomatoes,  are  extremely  valuable,  so  are  coarse 
breads  and  coarse  cereals.  Meat  and  eggs  produce  a  small 
amount  of  residue  but,  at  the  same  time,  should  be  allowed  in 
moderation  because  of  the  fact  that  these  patients  require  them 
in  their  dietary. 

Any  mechanical  derangement  of  the  gastrointestinal  tract 
should  be  corrected  if  possible.  Massage  is  of  value  in  this 
form  of  constipation.  Warm  olive  or  linseed  oil  enemas  given  at 
night  are  effective  in  softening  scybalous  masses  if  present.  Be- 
ginning with  one  ounce  this  may  be  increased  to  four  or  five 
ounces.  The  patient  should  retain  this  over  night.  This  may 
be  used  at  first  every  night  and  then  the  interval  should  be 
gradually  lengthened  until  it  is  used  only  once  a  week.  Some- 
times, at  first,  it  may  be  necessary  to  give  these  patients  some 
of  the  laxative  mineral  waters,  although  they  should  be  with- 
drawn as  soon  as  possible.  For  such  purposes  Hunyadi  Janos, 
Apenta,  Pluto  water,  Carlsbad  Salts,  or  plain  phosphate  of  soda 
may  be  used  each  morning  before  breakfast.  The  addition  of 
one  or  two  tablespoonfuls  of  bran  to  the  diet  two  or  three  times 
a  day;  or  agar-agar,  one  teaspoonful  to  a  tablespoonful  twice  a 
day  is  often  of  great  benefit.  What  is  desired  is  a  normal  motor 
response  on  the  part  of  the  intestinal  muscles. 

Hertz10  speaks  of  that  type  of  constipation  which  results 
from  a  delay  in  expelling  feces  from  the  rectum  as  dys- 
chezia.  This  is  allied  to  the  atonic  type.  I  will  quote  his  dis- 
cussion of  the  causes  which  operate  to  produce  this  type.  It 
will  be  seen  how  the  conditions  enumerated  above  as  being 
present  in  tuberculosis  will  operate  in  both  delaying  the  pas- 


10The   Sensibility  of  the  Alimentary   Canal,   Oxford  University  Press,   1911. 


ATONIC    CONSTIPATION  273 

sage  through  the  intestine  and  in  emptying  the  rectum  when 
it  has  been  reached.    He  says: 

"The  most  common  cause  of  dyschezia  is  the  habitual  disregard 
of  the  call  to  defecation  on  account  either  of  ignorance  or 
laziness  or  of  fear  of  pain  in  diseases  of  the  anus  and  the  neigh- 
boring organs.  I  have  already  described  how  the  sensation  of 
fulness  in  the  rectum  passes  off  owing  to  relaxation  of  the  tonic 
contraction  of  its  muscular  coat,  if  the  call  to  defecation  be 
disregarded.  If  it  is  again  disregarded  after  its  return  on  the 
arrival  of  more  feces  in  the  rectum,  further  relaxation  occurs. 
More  and  more  feces  accumulate  in  the  rectum,  the  muscular 
coat  of  which  becomes  more  and  more  relaxed.  As  the  force 
required  to  empty  the  rectum  when  overdistended  with  feces 
is  much  greater  than  that  required  to  empty  it  under  normal 
conditions,  evacuation  is  now  likely  to  be  incomplete,  even  if  a 
great  effort  be  made.  Consequently  feces  are  constantly  pres- 
ent in  the  rectum  instead  of  only  for  a  few  minutes  before  def- 
ecation, and  the  lumen  of  the  rectum  is  permanently  increased 
owing  to  the  atony  of  its  muscular  coat.  It  has  sometimes  been 
recommended  that  patients,  who  are  constipated  as  a  result  of 
irregularity  in  their  habits,  should  attempt  to  open  their  bowels 
after  breakfast,  but  should  not  obey  the  call  to  defecation  if 
felt  at  other  times  during  the  day.  Our  observations  show  that 
this  teaching  is  wrong,  and  that,  in  addition  to  the  regular  morn- 
ing effort  a  response  should  be  made  to  every  call,  however  in- 
convenient the  time.  For  the  occurrence  of  a  call  to  defecation 
always  means  that  for  some  reason  feces  have  just  passed  from 
the  pelvic  colon  into  the  rectum;  the  relaxation  of  tone  which 
follows  neglect  of  the  call  is  undesirable,  particularly  in  pa- 
tients with  dyschezia,  in  whom  a  certain  degree  of  atony  is  al- 
ready present. 

"Dyschezia  may  be  due  to  various  other  causes,  such  as  weak- 
ness of  the  voluntary  muscles  of  defecation  and  the  assumption 
of  an  unsuitable  position  during  defecation.  But  whatever  the 
primary  cause,  the  final  result  is  the  same.  The  incomplete  evac- 
uation of  the  rectum  results  in  the  accumulation  of  feces  and  in 
atonic  dilatation. 

"I  believed  at  first  that  the  absence  in  dyschezia  of  any  sen- 


274  DIGESTIVE  SYSTEM  IN   TUBERCULOSIS 

sation  when  the  rectum  contained  feces  was  due  to  a  blunting  of 
the  sensibility  of  the  mucous  membrane  as  a  result  of  the  ir- 
ritation produced  by  the  constant  presence  of  feces.  This  view 
was  shown  to  be  erroneous  by  our  observations  that  the  'rectal 
mucous  membrane  is  normally  insensitive  to  tactile  stimulation, 
and  that  the  call  to  defecation  depends  upon  the  sensibility  of 
the  muscular  coat  of  the  rectum.  The  few  experiments,  which 
I  have  at  present  had  the  opportunity  of  making,  suggest  that 
the  muscle-sense  is  not  impaired  in  most  cases  of  dyschezia,  as 
the  intrarectal  pressure  required  to  produce  the  call  of  defeca- 
tion is  not  greater  than  in  normal  individuals.  The  dyschezia 
depends  upon  the  atonic  dilatation  of  the  rectum,  an  abnormally 
large  quantity  of  feces  being  required  to  exert  the  normal  ade- 
quate pressure.  In  extreme  cases  a  blunting  of  the  muscle-sense 
may  also  occur;  in  such  cases  the  rapid  and  considerable  dis- 
tention produced  by  an  enema  injected  with  an  ordinary  syringe 
fails  to  produce  the  artificial  call  to  defecation,  which  in  most 
cases  of  dyschezia  results  in  a  movement  of  the  bowels. 

"There  is,  however,  an  entirely  distinct  class  of  dyschezia 
which  depends  upon  deficiency  of  the  muscle-sense  of  the  rec- 
tum. Congenital  deficiency  probably  causes  the  dyschezia,  which 
occurs  not  uncommonly  in  infants,  in  whom  the  slight  additional 
distention  produced  by  the  introduction  of  a  finger  or  a  piece 
of  soap  into  the  rectum  results  in  an  adequate  stimulus.  In  the 
majority  of  cases  the  muscle-sense  develops  as  the  infant  grows 
older,  but  congenital  deficiency  is  occasionally  the  starting-point 
of  dyschezia  which  lasts  through  life." 

The  place  of  low  enemas  in  the  relief  of  a  loaded  colon  de- 
serves some  consideration.  Realizing  the  importance  of  normal 
evacuations  some  faddists  have  gone  so  far  as  to  attempt  to  cure 
all  ills  by  injections  of  water  into  the  bowel.  Others,  appre- 
ciating that  this  was  a  fad  which  was  subject  to  abuse  and  ca- 
pable of  harm,  have  refused  to  see  any  good  in  it  and  have 
preferred  to  resort  to  the  use  of  laxatives  of  various  kinds.  If 
the  emptying  of  the  lower  bowel  depends  upon  the  muscle-sense, 
in  case  the  muscle  still  possesses  expulsive  power,  an  enema 
should  furnish  the  normal  stimulus  and  be  a  natural  measure  for 
relief.     It  also  has  an  added  advantage  of  softening  the  feces. 


SPASTIC   CONSTIPATION  275 

When  trying  to  get  patients  suffering  from  atonic  constipation 
away  from  cathartics,  I  believe  this  one  of  the  best  measures. 
The  amount  of  water  should  not  be  too  large  and  is  best  at  low 
temperature  which  stimulates  the  tissues  while  the  warm  re- 
laxes them. 

While  the  small  enema  of  low  temperature  is  of  value  in  atonic 
constipation  it  is  not  so  valuable  in  the  spastic  type  because  the 
delay  in  passage  is  due  to  increased  tone  and  is  farther  up  in 
the  canal.  This  type  is  produced  by  too  much  muscle  stimula- 
tion. Relaxing  measures  here  are  most  valuable.  If  injections 
are  used  in  this  type,  they  should  be  quite  warm  and  introduced 
in  such  a  manner  as  to  allow  the  water  to  travel  upward  toward 
the  cecum.  While  the  low  enema  for  the  relief  of  atonic  con- 
stipation should  not  be  held,  that  for  spastic  should  be  retained 
for  several  minutes. 

Spastic  Constipation. — Spastic  constipation  is  very  different 
from  atonic  constipation  in  its  nature  as  well  as  in  its  demands 
for  treatment.  While  atonic  constipation  is  due  to  a  failure  of 
the  bowel  to  respond  to  stimuli,  spastic  constipation  is  due  to 
an  increased  vagus  tonus,  and  an  irritative  condition  of  the  in- 
testinal tract  in  which  the  colon  is  the  seat  of  spastic  contrac- 
tion. Spastic  constipation  is  extremely  common  in  cases  of  hy- 
perchlorhydria.  Every  now  and  then  there  is  an  absorption  of 
toxins  with  the  resultant  toxic  syndrome.  The  patient  feels  dull, 
has  a  slight  headache,  and  loses  ambition.  The  bowel  move- 
ment is  entirely  different  in  form.  It  is  usually  of  soft  con- 
sistency, small,  ribbon-like  in  appearance,  and  the  patient  ex- 
periences an  unsatisfied  feeling  after  the  bowels  have  moved. 
This  form  of  constipation  is  associated  with  flatulence.  Gas  is 
a  very  common  factor  and  is  often  accompanied  by  colicky  pains. 
Individuals  who  are  naturally  of  the  vagotonic  type  are  very 
prone  to  suffer  from  this  form  of  constipation.  Cohnheim  says 
that  every  case  of  chronic  constipation  that  runs  its  course  with 
attacks  of  pain  belongs  to  the  spastic  variety,  in  which  inflam- 
matory and  catarrhal  changes  of  the  intestinal  tube  are  demon- 
strable. Patients  suffering  from  spastic  constipation  are  espe- 
cially harmed  by  laxatives.  In  some  cases  laxatives  even  in- 
crease the  constipation.     I  have  seen    cases    where    cathartics 


276  DIGESTIVE  SYSTEM  IN  TUBERCULOSIS 

caused  so  much  irritation  that  defecation  was  almost  impossible. 

The  principles  of  the  treatment  of  spastic  constipation  are 
the  opposite  from  those  for  atonic  constipation.  In  atonic  con- 
stipation we  endeavor  to  irritate  and  awaken  in  the  bowel  a 
response  to  stimulation;  while  in  spastic  constipation,  we  en- 
deavor to  allay  all  irritation  and  remove  all  factors  which  have 
a  tendency  to  provoke  irritation.  Eest  is  very  important  in 
these  cases.  Patients  do  better  when  kept  in  bed  for  a  time. 
Mechanical  measures  such  as  massage  are  contraindicated.  Hot 
packs  to  the  abdomen  for  a  period  of  two  hours  daily  are  of  great 
value.  The  oil  treatment,  as  mentioned  in  atonic  constipation, 
is  of  great  importance;  both  the  administration  of  paraffin  oil 
by  the  mouth  in  doses  of  one  or  two  ounces  per  day,  and  the  ad- 
ministration of  the  oil  enemas  to  be  retained  at  night. 

Diet  is  most  important.  Foods  which  produce  much  gas,  like- 
wise those  which  contain  large  quantities  of  residue,  should  be 
eliminated  from  the  dietary.  These  patients  should  not  drink 
cold  water;  but  large  quantities  of  hot  water  aid  in  relieving 
spasm.  One  or  two  glasses  should  be  taken  at  bedtime  and  the 
same  again  on  arising  in  the  morning.  Weak  tea  or  coffee  may 
be  used  sparingly,  although  the  patient  is  better  without  them. 
Sometimes  these  patients  may  be  allowed  orange  juice  in  the 
morning,  although,  at  other  times,  I  find  it  is  apt  to  produce 
colic ;  and,  if  hyperchlorhydria  is  present,  it  is  contraindicated. 
Milk,  buttermilk  (at  least  two  days  old),  all  soft  vegetables  such 
as  peas,  carrots,  mashed  potatoes,  baked  potatoes,  squash,  hom- 
iny (if  chewed  thoroughly)  and  cereals  may  be  used.  Vegetables 
are  best  in  purees.  Spinach,  Brussels  sprouts  and  cauliflower 
may  be  used  at  times  for  variety,  but  not  often;  cauliflower, 
particularly  being  prone  to  produce  gas.  Fruits  such  as  pears, 
peaches,  and  prunes  are  valuable.  Honey,  marmalade,  jellies 
and  jams  which  have  a  laxative  effect  through  chemical  action, 
are  very  useful.  Stale  white  bread,  toast,  and  zweibach  may 
be  used,  but  hot  bread,  biscuits,  and  coarse  bread  are  not  per- 
missible. Green  vegetables  must  sometimes  be  wholly  eliminated 
from  the  dietary  until  the  symptoms  have  been  relieved  for  some 
time. 

There  are  two  drugs  which  are  of  great  value  in  this  type 


SPASTIC    CONSTIPATION  277 

of  constipation,  atropin  and  bromides.  Atropin  can  usually  be 
given  in  1/200  grain  doses  three  times  a  day,  or  sometimes  even 
in  doses  of  1/100  grain  twice  or  three  times  a  day.  Ten  grains  of 
bromide  taken  three  or  four  times  a  day  will  often  answer,  though 
less  efficaciously,  the  same  purpose  as  atropin  in  allaying  nerv- 
ous irritability,  and  relaxing  the  intestinal  spasm.  "Where  gas 
is  extremely  troublesome  and  not  relieved  by  atropin  alone, 
the  following  prescription,  as  suggested  by  Cohnheim,  has  proved 
to  be  of  great  value  in  my  practice. 

IJ.     Tincturse  belladonnas  foliorum  5.0-10.0 

Spiritus  menthaa  piperita  5.0 

Tinctures  valerianic  15.0-20.0 

M. 

Sig.:  Thirty  drops  in  a  cup  of  hot  carminative  tea,  three  times 
a  day. 

Since  nutrition  is  such  an  important  factor  in  the  cure  of 
tuberculosis  and  in  the  maintaining  of  health,  after  once  re- 
gained, it  is  essential  that  we  should  not  be  satisfied  to  use  laxa- 
tives to  carry  our  patients  along  during  the  time  of  treatment, 
but  we  should  help  them  overcome  their  constipation  when  pos- 
sible. 

Biliousness  (So-called). — While  it  may  be  undignified  to  treat 
of  biliousness  in  a  discussion  of  this  kind,  yet  I  deem  it  im- 
portant to  emphasize  the  fact  that  it  is  not  an  entity  and  that 
it  has  no  place  in  our  literature.  Biliousness  is  supposed  to  be 
an  affection  of  the  liver,  but,  in  reality  is  an  acute  disturbance 
in  the  gastrointestinal  tract  accompanied  by  toxemia.  It  is  a 
group  of  symptoms, — those  of  headache,  feeling  of  malaise,  lack 
of  desire  for  work,  mental  hebetude,  sometimes  nervousness,  vari- 
able or  lack  of  appetite,  coated  tongue,  and  constipation.  This 
might  be  due  to  alterations  in  the  gastric  or  intestinal  secretions, 
to  disturbances  in  motility,  or  both;  or  it  might  be  due  to  some 
derangement  of  the  important  glands  associated  with  diges- 
tion. I  believe  the  greatest  factor  is  an  acute  stasis  of  bowel 
contents  with  absorption  of  toxins.  Inasmuch  as  this  condi- 
tion is  usually  associated  with  acute  constipation,  it  is  treated 
with  laxatives.     In  my  work  I  have   gradually   come  to  rely 


278  DIGESTIVE   SYSTEM  IN   TUBERCULOSIS 

particularly  on  one  laxative,  and  that  is,  castor  oil.  My  in- 
structions to  patients  when  suffering  from  this  chain  of  symp- 
toms is  to  stop  all  food  or  reduce  it  to  a  minimum  for  a  day,  and 
take  a  dose  of  castor  oil.  While  there  is  much  prejudice  against 
castor  oil,  I  find  in  my  own  practice  that  I  am  gradually  limit- 
ing myself  more  and  more  to  its  use.  It  seems  to  be  the 
most  efficacious  of  any  remedy  that  I  have  used.  It  can  be 
made  quite  pleasant  if  given  in  orange  juice.  Put  the  juice  of 
half  an  orange  in  the  bottom  of  a  small  medicine  glass.  Then 
put  in  from  three-quarters  of  an  ounce  to  an  ounce  of  oil  and 
cover  it  over  with  the  juice  of  the  other  half  of  the  orange.  Let 
the  patient  swallow  it  quickly.  It  may  also  be  taken  in  coffee, 
but  I  prefer  the  orange  juice.  Lemon  juice  can  take  the  place 
of  orange  juice,  although  it  is  not  quite  so  pleasant  to  take. 
"Where  there  is  great  objection  to  castor  oil,  saturated  solution 
of  epsom  salts  in  half  ounce  doses  may  be  used,  or  a  teaspoon- 
ful  of  saturated  solution  may  be  given  every  hour  until  a  thor- 
ough movement  of  the  bowels  has  been  obtained.  A  compound 
cathartic  pill,  at  night,  is  also  quite  valuable.  Calomel  may 
be  used  to  advantage.  It  may  be  used  in  small  doses  of  one- 
tenth  grain  every  hour  until  a  grain  has  been  given,  followed 
either  by  castor  oil  or  epsom  salts ;  or,  two  grains  may  be  given 
at  night,  a  half  grain  every  half  hour  until  the  quantity  is  taken, 
to  be  followed  by  oil  or  salts  the  following  morning.  The  grip- 
ing caused  by  calomel  may  be  prevented  by  the  use  of  some 
form  of  hyoscyamus  or  atropin.  In  my  practice  I  rarely  use  any 
other  remedy  than  castor  oil  or  an  enema.  These  are  non-irri- 
tating and  seem  to  be  the  least  harmful. 

Nervous  Influences  in  Gastrointestinal  Disturbances. — While 
errors  in  diet  are  many  and  pathological  changes  in  the  gastro- 
intestinal tract  not  infrequent,  yet  it  is  well  for  both  physician 
and  patient  to  learn  that  digestive  disturbances  are  just  as  likely, 
in  fact,  more  likely  to  come  from  within  the  patient  himself  and 
be  partially  or  wholly  within  his  control.  Emotional  influences, 
such  as  those  produced  by  pain,  anger,  fear  and  pessimism  are 
exceedingly  apt  to  disturb  the  gastrointestinal  function.  While 
we  are  constantly  looking  for  mechanical  and  secretory  disturb- 
ances in  the  intestinal  tracts  of  our  tuberculous  patients  we  must 


NERVOUS  DISTURBANCES  OF  DIGESTION  279 

not  forget  the  very  important  influence  which  emotion  bears  to 
them  and  to  nutrition  in  general.  If  we  can  keep  the  patient 
happy,  cheerful,  optimistic,  hopeful,  and  free  from  pain,  his  di- 
gestion is  better,  he  sleeps  better,  and  all  organs  functionate 
better.  On  the  other  hand,  if  the  patient  is  pessimistic,  worry- 
ing about  every  little  thing  that  comes  up  and  allowing  himself 
to  be  depressed  and  discouraged  by  trifles,  he  is  apt  to  have  many 
attacks  of  indigestion  which  he  could  escape  by  self-control. 

There  is  a  great  deal  in  the  saying,  "Laugh  and  grow  fat," 
because  with  happiness  comes  better  digestion  and  better  assimila- 
tion. 

The  effect  of  emotion  on  peristalsis  is  shown  by  Cannon.11  He 
says: 

"In  my  earliest  observations  on  the  stomach  I  had  difficulty, 
because  in  some  animals  peristalsis  was  perfectly  evident,  in 
others  there  was  no  sign  of  activity.  Several  weeks  passed  be- 
fore I  discovered  that  this  difference  in  response  to  the  presence 
of  food  in  the  stomach  was  associated  with  the  difference  of  sex. 
The  male  cats  were  restive  and  excited  on  being  fastened  to  the 
holder,  and  under  these  circumstances  gastric  peristalsis  was  ab- 
sent; the  female  cats,  especially  if  elderly,  submitted  with  calm- 
ness to  the  restraint,  and  in  them  peristaltic  waves  took  their 
normal  course.  Once  a  female  with  kittens  turned  from  her  state 
of  quiet  contentment  to  one  of  apparent  restless  anxiety.  The 
movements  of  the  stomach  immediately  stopped  and  only  started 
again  after  the  animal  had  been  petted  and  began  to  purr.  I 
later  found  that  by  covering  the  cat's  mouth  and  nose  with  the 
fingers  until  a  slight  distress  of  breathing  occurred  the  stomach 
movements  could  be  stopped  at  will.  Thus,  in  the  cat,  any 
sign  of  rage,  or  distress,  or  mere  anxiety,  was  accompanied  by  a 
total  cessation  of  the  movements  of  the  stomach.  I  have  watched 
with  the  x-rays  the  stomach  of  the  male  cat  for  more  than  an 
hour,  during  which  time  there  was  not  the  slightest  beginning 
of  peristaltic  activity,  and  yet  the  only  visible  indication  of  ex- 
citement in  the  animal  was  a  continued  to-and-fro  twitching  of 
the  tail.  '  *    \m{    p§  ^ 

"What  is  true  of  the  cat  has  been  proved  true  also  of  the  rab- 


uThe  Mechanical  Factors  of  Digestion,  Longmans,  Green  &  Co.,  New  York,  1911. 


280  DIGESTIVE  SYSTEM  IN   TUBERCULOSIS 

bit,  dog,  and  guinea  pig.  A  female  cat  that  ordinarily  lies 
quietly  in  the  holder,  and  makes  no  demonstration  will  occa- 
sionally, with  only  a  little  premonitory  restlessness,  suddenly  fly 
into  a  rage,  lashing  her  tail  from  side  to  side,  pulling  and  jerk- 
ing with  every  limb,  and  biting  at  everything  near  her  head. 
During  such  excitement  and  for  some  moments  after  the  animal 
has  become  pacified  again,  the  movements  of  both  the  large  and 
small  intestines  entirely  cease.  The  opposing  influences,  reach- 
ing the  alimentary  canal  by  way  of  the  sympathetic  system  dur- 
ing emotional  excitement,  can  wholly  destroy  both  the  secretory 
and  motor  activities  which  have  been  started  by  the  bulbar 
system.  The  importance  of  avoiding  so  far  as  possible  the 
states  of  worry  and  anxiety,  and  of  not  permitting  grief  and 
anger  and  other  violent  emotions,  to  prevail  unduly,  is  not 
commonly  appreciated;  for  the  subtle  alterations  wrought  by 
these  emotional  disturbances  are  uncommon  to  consciousness 
and  have  become  clearly  demonstrated  solely  through  physio- 
logical studies.  Only  as  the  consequences  of  mental  states  favor- 
able and  unfavorable  to  normal  digestion  are  better  understood 
can  good  results  be  sought  and  bad  results  avoided,  or,  if  not 
avoided,  regarded  and  treated  with  intelligence." 

Amyloid  Degeneration. — In  advanced  tuberculosis  the  vessels 
of  the  intestinal  tract  often  become  the  seat  of  amyloid  de- 
generation. This  causes  the  interference  with  secretion,  motility, 
and  absorption,  and  is  especially  serious  because  it  cannot  be 
remedied. 

Errors  in  Diet. — Errors  in  diet  should  be  avoided  as  much 
as  possible  where  a  high  state  of  nutrition  is  desirable.  Errors 
in  diet  may  be  due  to  the  eating  of  the  Avrong  kind  of  food, 
or  to  eating  too  much  or  too  little  food,  or  to  eating  food 
which  is  not  suited  to  the  nutritive  requirements  of  the  patient 
or   the   peculiar   digestive   conditions   present. 


CHAPTER  XI. 

COMPENSATORY  CHANGES  IN  THE  THORACIC  AND 

ABDOMINAL  CAVITIES  RESULTING  FROM 

PULMONARY  TUBERCULOSIS. 

When  we  consider  the  compensatory  changes  which  take  place 
in  pulmonary  tuberculosis,  particularly  in  the  advanced  disease, 
we  are  forced  to  see  clearly  that  while  this  is  primarily  a  disease 
of  the  lung,  it  is  accompanied  by  secondary  changes  which  affect 
every  organ  in  the  thoracic  and  abdominal  cavities. 

These  compensatory  changes  must  be  discussed  together.  They 
are  so  intimately  related  that  it  is  impossible  to  completely  sepa- 
rate those  which  take  place  between  the  organs  within  the  chest 
itself  from  those  which  take  place  between  the  organs  of  the 
abdominal  and  thoracic  cavities.  This  can  be  understood  by  con- 
sidering the  thoracic  and  abdominal  cavities  as  one  large  cavity 
with  a  flexible  partition  separating  them.  No  increase  of  tissue 
or  loss  of  tissue  can  occur  in  one  part  of  this  cavity  without  af- 
fecting all  parts ;  neither  can  any  increase  or  decrease  in  the  con- 
tour of  the  walls  take  place  in  any  one  portion  of  this  cavity 
without  affecting  other  or  all  portions. 

The  symptoms  which  are  produced  as  a  result  of  the  disturbed 
function  of  the  organs  and  parts  which  take  part  in  the  produc- 
tion of  compensation  are  such  as  might  be  caused  by  other  condi- 
tions present  as  well;  consequently,  the  reader  must  bear  in 
mind  that  while  the  symptoms  mentioned  may  be  caused  by  the 
conditions  under  discussion,  they  are  not,  necessarily,  wholly 
due  to  them.  It  is  often  impossible  to  assign  the  true  cause  to 
each  symptom  because  several  conditions  all  of  which  are  pres- 
ent, are  capable  of  producing  it.  So,  in  reading  this  chapter,  let 
it  be  borne  in  mind  that  the  symptoms  here  mentioned  may  be 
caused  by  many  conditions,  among  which  are  the  shifting  of  or- 
gans and  resulting  compensatory  changes  described. 

Compensatory   Changes   Taking  Place  Within  the   Thoracic 


282  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

Cavity. — In  order  to  understand  the  extent  of  compensatory- 
change  which  takes  place  between  the  organs  within  the  thorax 
in  pulmonary  tuberculosis,  it  is  necessary  to  consider  the  thoracic 
cavity  as  a  cone-shaped  cavity  whose  walls  on  all  sides,  except 
the  base  which  is  a  thin  flexible  membrane,  are  made  up  of  a 
framework  of  bones.  All  of  these  walls,  even  the  bony  ones,  are 
somewhat  yielding  to  pressure  but  they  maintain  their  position 
and  shape  under  conditions  of  health,  and,  as  a  rule,  change  their 
contour  only  when  the  organs  within,  or  adjacent,  are  affected 
by  pathological  changes.  Changes  in  the  contour  of  the  flexible 
membranous  wall  (diaphragm)  occur  and  will  be  discussed  fully 
later  on;  but  it  is  necessary  to  state  at  this  time  that  the  posi- 
tion of  the  diaphragm  is  a  peculiarly  sensitive  one.  It  depends 
upon  the  relative  pressures  in  the  thoracic  and  abdominal  cav- 
ities. Normally,  the  pressure  in  the  thoracic  cavity  is  negative 
while  that  of  the  abdominal  cavity  is  positive.  The  negative 
pressure  of  the  thoracic  cavity  tends  to  draw  or  suck  the  dia- 
phragm upward,  while  the  positive  pressure  of  the  abdominal 
cavity  tends  to  push  it  upward  and  hold  it  there. 

The  thoracic  cavity  is  divided  by  the  structures  of  the 
mediastinum  into  a  right  and  left  portion.  These  dividing  struc- 
tures are  movable.  They  shift  from  one  side  to  the  other  as  con- 
ditions demand.  They  respond  to  any  increase  and  decrease  of 
substance  or  pressure  in  either  the  lung  or  pleura  by  shifting 
their  position.  In  this  connection  the  compensatory  character 
of  lung  tissue  must  also  be  considered.  The  lung  is  subject  to 
many  pathological  conditions  in  some  of  which  there  is  a  loss  of 
tissue  either  confined  to  some  small  area  or  affecting  a  large 
area;  in  others  the  air  cells  dilate  and  the  lung  enlarges,  either 
in  circumscribed  areas  or  generally.  As  a  rule,  the  loss  of  tis- 
sue is  compensated  for,  as  far  as  possible,  by  enlargement  of 
other  portions  of  the  lung  or  lungs  (compensatory  emphysema). 

These  compensatory  changes  are  unavoidable ;  in  fact,  they  are 
very  desirable  under  the  circumstances;  yet  they  are  abnormal 
conditions  which  are,  according  to  their  extent,  productive  of 
symptoms  of  greater  or  lesser  severity. 

To  appreciate  the  compensatory  changes  which  take  place  be- 
tween the  two  sides  of  the  thorax  a  correct  conception  of  the 


NATURE  OP  MEDIASTINUM  283 

mediastinum  must  be  had.  The  mediastinum  may  be  likened  to 
a  swinging  door  in  the  center  of  the  thoracic  cavity.  It  swings 
back  and  forth  to  either  side  as  necessity  demands.  It  is  hinged 
to  the  posterior  wall  by  the  arteries  and  veins  which  pass  be- 
tween the  large  blood  vessels  and  the  intercostal  structures.  The 
anterior  portion  is  fastened  to  the  under  surface  of  the  sternum 
by  the  pericardium, — a  structure  which  varies  in  size,  it  being 
usually  large,  and,  in  some  instances,  excessively  large,  permits 
of  considerable  freedom  in  the  motion  of  the  anterior  portion  of 
the  door  (to  carry  out  the  figure)  ;  consequently  a  contraction 
of  the  tissues  on  one  side,  with  compensatory  enlargement  on  the 
other,  permits  the  door  to  swing  toward  the  side  of  contraction. 
The  extent  of  its  motion  is  limited  only  by  the  size  of  the  peri- 
cardium and  the  amount  of  play  that  it  will  permit. 
In  discussing  this  subject  in  a  former  paper,1  the  writer  said: 
"It  is  somewhat  surprising  that  these  conditions  have  not  re- 
ceived more  attention  from  clinicians  when  we  consider  the  fact 
that  they  are  present  and  produce  symptoms  in  nearly  all  patients 
who  are  suffering  from  tuberculosis.  There  are  displacements 
of  the  heart  in  some  form  and  to  some  degree  in  practically  all 
cases  where  either  a  lessening  or  increase  in  the  volume  of  the 
lung  occurs.  The  function  of  the  diaphragm  is  interfered  with 
from  the  very  beginning  of  tuberculosis.  It  is  displaced  either 
upwards  or  downwards  in  nearly  all  patients  who  go  on  to  an 
advanced  stage  of  the  disease,  the  dislocation  depending  upon 
the  relationship  between  the  intra-abdominal  and  intrathoracic 
pressures. 

"The  symptoms  which  result  from  these  conditions  can  only  be 
understood  in  connection  with  the  physiology  of  the  heart  and 
diaphragm.  The  heart  is  normally  placed  in  the  thoracic  cav- 
ity in  a  position  which  enables  it  to  perform  its  function  with 
ease.  The  circulation  of  the  blood  is  aided  by  every  normal 
respiration.  Any  condition  which  changes  the  position  of  the 
heart,  putting  it  in  a  position  less  favorable  to  action,  and  any 
condition  which  interferes  with  the  full  and  free  respiratory 


iDisplacements  of  the  Heart  and  Diaphragm,  Together  With  Disturbances  in  the  Func- 
tion of  the  Latter  as  Causes  of  Symptoms  in  Pulmonary  Tuberculosis,  Interstate  Medical 
Journal,   vol.  xviii,   No.  6,   1911. 


284  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

movements,  therefore,  interferes  with  the  circulation  of  the 
blood." 

Aside  from  the  symptoms  due  to  abnormal  conditions  in  the 
heart  and  diaphragm  there  are  many  which  are  due  to  the 
changes  in  the  lung. 

When  ulceration,  fibrosis,  or  both  combined,  are  sufficiently  ex- 
tensive to  call  for  a  compensatory  emphysema,  the  respiratory 
function  is  more  or  less  interfered  with  and  circulatory  disturb- 
ances make  their  appearance. 

The  thorax  is  a  closed  cavity  in  which  a  negative  pressure  ex- 
ists, and  at  every  physiological  enlargement  of  this  cavity,  such 
as  occurs  during  inspiration,  the  air  in  the  bronchi  and  air  cells 
attempts  with  all  the  pressure  of  the  atmosphere  back  of  it,  to 
fill  in  the  enlarged  space.  Likewise  with  every  pathological 
diminution  of  pulmonary  tissue  such  as  occurs  in  tuberculosis 
when  destruction  of  tissue  takes  place,  the  pressure  in  the  re- 
maining portions  of  the  air  chambers  is  relatively  decreased.  The 
result  in  these  pathological  conditions  where  the  pulmonary  tis- 
sue has  wasted  to  any  extent,  is  that  the  thin-walled  air  cells  of 
the  remaining  portion  of  the  lung  yield  to  the  atmospheric  pres- 
sure, dilate  and  produce  an  enlargement  of  that  portion  of  the 
lung  involved  (compensatory  emphysema). 

An  equilibrium  between  the  intrathoracic  and  intra-abdominal 
pressures  on  the  one  hand  and  between  these  and  the  atmospheric 
pressure  on  the  other  hand,  both  as  it  surrounds  the  surface  of 
the  body  and  as  it  fills  the  air  chambers  of  the  lung,  must  be 
maintained  under  all  circumstances  if  the  proper  functionating 
capacity  of  the  various  organs  in  these  cavities  is  to  be  main- 
tained. 

To  the  extent  to  which  pulmonary  tuberculosis  disturbs  this 
equilibrium  without  full  compensation;  and  to  the  extent  to 
which  the  compensatory  changes  which  occur,  take  place  to  the 
disadvantage  of  the  various  functionating  powers  of  the  organs 
concerned,  is  the  disease  responsible  for  the  pathological  changes 
and  untoward  symptoms. 

Of  the  many  pathological  changes  which  take  place  in  the 
lungs  and  pleura,  some  cause  so  little  change  in  tissue  that  their 
effect  on  the  mediastinum  and  diaphragm  is  negligible;  but  any 


COMPENSATORY   CHANGES  IN  LUNG  285 

considerable  loss  of  lung  tissue,  or  any  marked  decrease  in  the 
respiratory  function  in  one  part  of  the  lung,  is  followed  by  a 
compensatory  increase  in  other  parts. 

Man  is  naturally  endowed  with  an  excess  of  lung  tissue  over 
what  is  actually  needed  for  the  ordinary  acts  of  life.  This  en- 
ables him  to  respond  to  unusual  effort  and  strain  by  calling  his 
reserve  lung  power  into  action.  It  has  been  estimated  that  a 
man  can  exist  on  about  one-twelfth  of  his  lung  area;  be  fairly 
active  on  one-half  and  perform  most  of  the  ordinary  acts  of  life 
without  strain,  on  two-thirds.  A  person  who  has  lost  one-third 
of  his  pulmonary  area,  however,  would  not  be  able  to  measure 
up  to  any  marked  sudden  effort  or  strain,  for  he  has  no  reserve 
lung  area  to  call  into  action. 

In  nature 's  attempts  to  compensate  for  loss  of  tissue,  she  some- 
times defeats  her  purpose  by  producing  conditions  which  by  them- 
selves are  deleterious.  Thus,  at  times,  such  a  degree  of  compensa- 
tory emphysema  is  produced  in  advanced  destructive  tubercu- 
lous lesions  that  this  of  itself  proves  to  be  harmful  to  the  pa- 
tient, by  the  reduced  functionating  capacity  of  the  lung  tissue 
involved,  and  by  the  extra  burden  thrown  on  the  heart  as  a  re- 
sult of  it.  When  an  extensive  degree  of  emphysema  is  present 
the  heart  is  less  able  to  cope  with  the  extra  work  too,  because 
it  has  been  subjected  to  more  or  less  degenerative  change  owing 
to  the  destructive  process  in  the  lung  and  the  general  malnutri- 
tion and  because  it  is  forced  out  of  its  natural  position  to  the 
right  or  to  the  left  and  is  working  at  a  disadvantage  on  this  ac- 
count. 

Shifting  of  Mediastinum. — The  shifting  of  the  mediastinum  to 
a  recognizable  degree  is  extremely  common  in  advanced  tuber- 
culosis. The  amount  of  this  shifting  depends  on  a  number  of 
factors.  The  mediastinum,  as  a  whole,  shifts  to  the  left  easier 
than  to  the  right.  The  anterior  mediastinum  shifts  easier  than 
the  posterior  because  the  aorta  in  the  posterior  mediastinum  is 
held  fairly  firmly  in  its  position  by  the  intercostal  branches  which 
it  gives  off  to  pass  into  the  structures  on  either  side  of  the  verte- 
bral column.  The  large  vessels  are  also  fixed  to  a  certain  extent 
by  the  large  branches  which  pass  up  into  the  neck.  The  heart,  on 
the  other  hand,  which  fills  the  anterior  mediastinum  in  its  low- 


286  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

er  portion,  is  contained  in  the  pericardium,  a  sac  varying  much 
in  size,  and  allowing  of  considerable  movement  on  the  part  of 
the  heart  lying  within.  The  amount  of  movement  which  the 
heart  can  make  in  health  and  the  ease  as  well  as  the  extent  to 
which  the  heart  moves  under  pathological  conditions  depends 
largely  upon  the  size  of  the  pericardium.  While  the  structures 
in  the  upper  portion  of  the  mediastinum  do  not  shift  their  posi- 
tion readily,  yet  they  offer  so  little  resistance  that  the  enlarged 
lung  on  the  side  opposite  the  destruction  may  gradually  force  its 
way  between  it  and  the  anterior  surface  of  the  chest  wall  over 
to  the  other  side  of  the  median  line.  In  one  of  my  cases  (Fig. 
40)  the  left  lung  had  formed  a  new  lobe  which  had  forced  its  way 
three  inches  beyond  the  median  line  to  the  right. 

The  pericardium  is  attached  anteriorly  to  the  under  surface  of 
the  sternum,  inferiorly  to  the  diaphragm,  superiorly  to  the  great 
vessels,  and  laterally  to  the  right  and  left  pleura. 

In  advanced  tuberculosis,  the  inferior  and  two  lateral  attach- 
ments are  unstable  and  subject  to  considerable  change  in  posi- 
tion, thus  allowing  the  heart  to  shift  its  position. 

Displacement  of  the  Heart. — In  my  practice  I  have  found  severe 
destructive  changes  of  wide  extent  to  be  most  common  in  the 
left  lung,  the  upper  lobe  being  involved,  as  a  rule,  more  exten- 
sively than  the  lower;  although  large  cavities  and  extensive 
fibrosis  are  often  formed  in  the  lower  lobe  also.  The  right  lung 
is  severely  diseased  less  often;  but  when  it  is,  the  conditions 
duplicate  those  in  the  left,  the  upper  portion  showing  the  more 
extensive  process.  That  the  upper  lobe  should  be  the  seat  of 
the  more  extensive  involvement  is  evident  from  the  fact  that  the 
primary  pulmonary  infection  is  usually  near  the  apex  whether  it 
be  the  first  apex  involved  or  the  extension  to  the  other  lung ;  and, 
the  disease  spreads  downward  contiguously  from  the  original 
metastasis.  From  this  fact  it  is  also  evident  that  the  greatest 
evidence  of  healing  with  the  formation  of  fibrous  tissue  should 
be  found  in  the  upper  lobes  where  the  lesion  is  oldest  and  where 
the  process  was  present  before  the  patient's  recuperative  powers 
were  so  severely  taxed.  "While  we  often  find  extensive  healing 
in  the  lower  lobes,  yet,  being,  as  a  rule,  a  later  infection,  heal- 


-. E 


C    . 


p 


1 


Fig.  40. — Illustrating  the  distortion  of  the  thoracic  viscera  in  a  patient  with  a  marked 
destructive  lesion  in  the  right  lung,  and  marked  compensatory  changes  in  the  left. 
A,  the  upper  lobe  on  the  right,  is  a  small  fibroid  mass;  B,  the  middle  lobe,  is  only  a  fibrous 
string;  C,  the  lower  lobe,  barely  presents  anteriorly,  but  posteriorly,  was  the  seat  of 
emphysema;  D,  three-fourths  of  the  heart  lies  to  the  right  of  the  median  line;  E,  the 
upper  lobe  on  the  left  represents  a  large  portion  of  the  lung  which  presents  anteriorly. 
A  new  lobe  has  been  formed,  pushing  through  the  anterior  mediastinum  to  a  distance  of 
three  inches  beyond  the  median  line;  F,  the  lower  lobe  is  also  markedly  emphysematous; 
G,  trachea. 


DISPLACEMENT   OP  HEART  287 

ing  does  not  take  place  as  extensively  here  as  in  the  upper  lobes. 

The  direct  factors  which  cause  the  heart  to  change  its  posi- 
tion are  the  loss  of  lung  tissue  and  coincident  compensatory  en- 
largement of  other  portions.  In  the  final  analysis,  however,  it  is 
due  to  the  necessity  of  maintaining  a  definite  pressure  equilibrium 
between  the  air  containing  chambers  within  the  lung  and  the  at- 
mospheric air  surrounding  the  outer  chest  wall.  The  bony  cage 
yields  some,  but  cannot  make  up  for  the  entire  deficiency ;  neither 
would  we  expect  it  to  yield  except  after  all  more  pliable  struc- 
tures had  yielded  to  their  full  extent,  unless  the  contraction  of 
the  muscles  was  a  factor.  The  diaphragm  pushes  upward,  but 
this  too  is,  limited  in  its  ability  to  satisfy  the  demand,  so  it  must 
be  met  by  the  tissues  within  the  thorax  itself.  The  pleural  sac 
remains  closed  because  of  its  negative  pressure,  or  it  may  be 
obliterated  because  of  adhesions;  consequently  the  only  method 
of  meeting  the  demand  which  cannot  be  met  by  the  diminishing 
of  the  size  of  the  bony  cage,  and  by  the  ascent  of  the  diaphragm, 
is  by  enlarging  (compensatory  emphysema)  that  portion  of  the 
lung  which  is  not  destroyed  by  ulceration  and  fibrosis. 

Such  changes  disturb  the  nicely  balanced  symmetry  which  ex- 
ists normally  between  the  two  sides  of  the  thoracic  cavity  and 
between  it  and  the  abdominal  cavity  and  cause  a  distortion  of 
all  the  structures  within  the  thoracic  cage.  The  amount  of  dis- 
tortion is  determined  by  the  amount  of  destruction  in  the  pul- 
monary tissue,  the  degree  of  compensatory  emphysema,  and  the 
size  of  the  pericardium  and  the  amount  of  displacement  which 
it  will  permit  the  heart  to  undergo. 

The  entire  mediastinum  is  disturbed  in  its  relationship  but  the 
heart  is  the  organ  that  shows  the  greatest  displacement.  These 
displacements  vary  according  to  the  character  of  the  changes  in 
the  lung.  In  this  present  discussion  I  am  omitting  considera- 
tion of  those  acute  displacements  which  occur  as  a  result  of 
changes  in  the  pleura. 

I  have  noted  the  following  relationship  between  displacements 
of  the  heart  and  the  pulmonary  involvement. 

1.  If  there  is  a  small  lesion  in  one  or  both  lungs,  there  is  no 
appreciable  change  in  the  position  of  the  heart. 

2.  If  the  lesion  becomes  more  extensive  and  heals  there  is  a 


288  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

tendency  to  draw  the  borders  of  the  lung  upward,  and  with  them 
the  pericardium.  This  is  counteracted,  however,  as  a  rule,  by  a 
compensatory  emphysema  developing  which  affects  the  lower 
portion  of  the  lungs  and  holds  the  diaphragm  somewhere  near 
its  normal  position  or  even  pushes  it  lower.  I  have  seen  a  few 
hearts  that  seemed  to  be  raised  in  toto  because  of  such  a  double 
lesion.  The  effect  of  such  a  change  in  position  is  to  shorten  the 
distance  between  the  apex  and  the  large  vessels,  thus  producing 
a  tendency  to  pouch  the  aorta. 

3.  At  times,  when  a  double  involvement  exists  at  the  apices, 
the  opposite  occurs.  A  high  grade  of  compensatory  emphysema 
develops  pushing  the  diaphragm  downward.  The  heart  follows 
the  diaphragm  and  hangs  suspended  from  the  great  vessels  the 
same  as  it  does  in  those  enteroptotic  individuals  who  are  occa- 
sionally seen  who  suffer  from  suspensio  cordis.  I  have  seen  sev- 
eral cases  such  as  these.  When  examined  by  the  fluoroscope  during 
inspiration,  as  the  diaphragm  sinks,  the  heart,  being  unable  to 
follow,  hangs  suspended,  dragging  on  the  aorta.  Such  is  the 
case  in  many  patients  of  the  asthenic  type. 

4.  The  most  common  extensive  displacement  as  mentioned 
above,  is  the  one  when  the  heart  is  displaced  to  the  left  and 
upwards  (Fig.  41).  In  advanced  tuberculosis  a  degenerative 
process  which  goes  on  to  the  destruction  of  the  greater  portion 
of  the  upper  left  lobe  is  not  uncommon.  A  portion  of  the  lower 
lobe  is  usually  destroyed  at  the  same  time.  Such  a  condition 
may  occur  and  yet,  the  patient,  if  properly  treated,  obtain  an 
arrestment  of  his  disease  and  regain  fairly  good  health.  If  an 
arrestment  takes  place  it  is  accompanied  by  the  formation  of 
fibrous  tissue  and  contraction.  The  walls  of  the  cavity  or  cavities 
are  compressed  and  the  lung  area  which  was  involved  in  the 
severe  destructive  process  is  greatly  reduced  in  size.  At  times 
a  very  marked  contraction  occurs,  even  though  it  was  not  pre- 
ceded by  a  destructive  process  with  cavity  formation,  the  process 
from  the  start  being  one  accompanied  by  the  formation  of  fibrous 
tissue.  Under  such  circumstances  compensation  takes  place,  not 
only  in  the  lower  portions  of  the  left  lung,  but  also  in  the  right 
lung.  Equilibrium  can  only  be  established  when  the  space  in 
the  thorax  occupied  by  that  portion  of  the  destroyed  and  con- 


DISPLACEMENT  OP  HEART 


289 


tracted  left  lung  is  occupied  by  other  tissue.  To  this  end,  the 
right  lung  enlarges  under  the  pressure  of  the  atmosphere  and 
gradually  pushes  over  against  the  mediastinum,  forcing  the 
heart,  which  is  also  being  pulled  by  the  contracting  lung,  over 
toward  the  left.  The  diaphragm  pushes  up  at  the  same  time 
from  below  and  this  forces  the  apex  of  the  displaced  heart  up- 


.  Fig.  41. — Illustrating  schematically  the  displacement  of  the  heart  to  the  left.  It  will  be 
seen  that  the  left  half  of  the  diaphragm  is  pushed  upward,  and  the  apex  of  the  heart 
follows  the  fifth  interspace.  This  displacement  has  a  tendency  to  reduce  the  curve  in  the 
arch  of  the  aorta.  The  trachea  may  be  drawn  entirely  to  the  left  of  the  median  line  as 
shown  in  the  cut. 

wards,  the  two  forces  together  pushing  it  to  the  left  and  up- 
ward. This  displacement  is  often  so  great  that  the  entire  heart 
is  to  the  left  of  the  sternum. 

This  displacement  not  only  causes  the  heart  to  be  thrown  out 
of  its  normal  position  and  work  at  a  disadvantage  because  of 


290 


COMPENSATORY   CHANGES  IN   TUBERCULOSIS 


this ;  but  the  pericardium  still  maintaining  its  attachments  to  the 
sternum  and  center  of  the  diaphragm  is  unquestionably  pushed 
so  far  from  its  moorings  that  its  surfaces  are  brought  into  con- 
tact in  such  a  manner  that  it  materially  reduces  the  pericardial 
space. 

This  altered  position  of  the  heart  causes  marked  dragging  on 


Fig.  42. — Illustrating  schematically  marked  displacement  of  the  heart  to  the  right.  It 
will  be  noticed  that  the  heart  is  pushed  upward  and  over.  The  right  side  of  the  diaphragm 
assumes  a  high  position;  while  the  left  side  assumes  a  low  one  in  order  to  accommodate 
the  left  lung  which  is  the  seat  of  compensatory  emphysema.  When  this  displacement  is 
present,  the  curve  in  the  arch  of  the  aorta  is  lessened  with  a  tendency  to  pouching. 

the  great  vessels  at  its  base,  decreasing  the  curve  of  the  arch  of 
the  aorta,  thus  bringing  about  a  condition  which  interferes  with 
the  free  flow  of  blood  into  the  systemic  arteries. 

The  same  dragging  force  exerts  a  pull  upon  the  other  ves- 


DISPLACEMENT  OP  HEART  291 

sels  at  the  base  of  the  heart,  drawing  the  pulmonary  artery  and 
large  veins  out  of  their  normal  course  and  interfering  with  the 
outflow  of  blood  from  the  right  ventricle  and  the  return  flow 
to  the  auricles.    Dragging  on  the  trachea  often  provokes  cough. 

5.  If  the  severe  destruction  occurs  in  the  right  lung,  instead 
of  the  left,  the  heart  is  displaced  upwards  and  to  the  right 
as  shown  in  Fig.  42.  When  the  destruction  and  contraction  are 
very  marked,  the  heart  may  be  displaced  entirely  to  the  right 
of  the  sternum,  but  this  is  rare  compared  with  the  total  displace- 
ment to  the  left. 

This  displacement  is  not  as  natural  as  that  toward  the  left. 
The  heart  lies  on  the  diaphragm  in  such  a  way  that  it  can  be 
pushed  to  the  left  with  ease,  but,  when  pushed  to  the  right,  its 
apex  meets  the  obstruction  of  the  central  portion  of  the  di- 
aphragm and  the  underlying  liver.  And,  too,  the  diaphragm  and 
liver  are  pushing  up  into  the  thoracic  space  at  the  same  time,  in 
order  to  help  compensate  for  the  loss  of  tissue.  The  result  is 
that  the  heart  as  a  whole  is  lifted  as  well  as  pushed  over  to  the 
right. 

The  effect  of  such  a  new  position  is  to  push  up  and  widen  the 
arch  of  the  aorta.  This  creates  a  relaxed  condition,  with  a  ten- 
dency to  pouching. 

The  distortion  of  the  other  vessels  is  also  marked  and,  the 
free  flow  of  blood  to  and  from  the  heart  is  impeded. 

The  same  constriction  of  the  pericardial  space  ensues  as  above 
described  and  the  heart  is  forced  to  work  in  a  position  even  more 
unfavorable  than  that  mentioned  above. 

Not  only  is  it  more  difficult  for  this  displacement  to  take  place, 
but  in  my  experience,  it  proves  more  embarrassing  to  the  heart 
which  gives  out  more  quickly  under  it. 

As  a  result  of  these  marked  compensatory  displacements  in 
the  thorax,  the  trachea  is  drawn  or  pushed  over  toward  the  side 
which  is  the  seat  of  the  destructive  process.  This  can  usually 
be  determined  by  noting  the  position  of  the  larynx  and  following 
the  direction  of  the  trachea  as  it  passes  down  to  enter  the 
thorax.  It  is  a  suggestive  point  in  the  diagnosis  of  this  condi- 
tion. 


292  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

In  these  displacements  the  recurrent  laryngeal  nerve  is  often 
disturbed,  a  brassy  cough  resulting  similar  to  that  which  is 
often  described  in  aneurysm.  At  times  there  is  also  noted  a 
marked  difference  in  the  blood  pressure  in  the  two  arms  which 
might  also  add  to  the  suspicion  of  aneurism. 

Effect  of  Displacements  of  Heart. — To  understand  the  full  sig- 
nificance of  these  displacements  and  their  effect  upon  the  heart, 
we  must  discuss  other  factors  than  those  just  mentioned  which 
have  a  tendency  to  embarrass  the  heart's  action.  Among  such 
are  the  pleural  adhesions  which  are  nearly  always  present;  the 
displaced  diaphragm  with  its  consequent  disturbed  function  which 
will  be  discussed  later  in  this  chapter;  the  resistance  offered  in 
the  pulmonary  circulation  by  the  destruction  of  vessels  in  the 
contracted  areas  as  well  as  the  embarrassment  imposed  by  the 
emphysematous  areas;  the  thickening  of  the  arteries  which  re- 
sults from  the  tuberculous  infection,2  and  the  degenerations  of 
the  heart  muscle  which  result  from  the  action  of  the  specific  bacil- 
lary  and  other  toxins  as  well  as  the  malnutrition  present. 

The  heart  is  called  upon  to  carry  an  enormously  increased 
load;  at  the  same  time  its  muscle  is  weakened,  and  it  is  forced 
to  work  under  disadvantageous  conditions. 

The  cause  of  death  in  these  cases  of  severe  destruction  and 
marked  displacement  is  nearly  always  degeneration  and  dila- 
tation. The  patients  live  as  long  as  their  hearts  will  permit 
them  to  live. 

The  symptoms  which  occur  during  the  time  that  the  heart  is 
changing  its  position  depend  on  the  rapidity  with  which  such 
change  takes  place.  In  some  cases  we  see  the  displacement  take 
place  rapidly  as  in  the  case  mentioned  in  one  of  my  former 
papers,3  but,  as  a  rule,  several  months  are  occupied  in  shifting 
the  position.  Since  the  diaphragm  is  disturbed  in  its  function 
and  since  there  is  evidence  of  activity  in  the  pulmonary 
tissue  at  the  same  time,  it  is  extremely  difficult  to  sepa- 
rate the  symptoms  which  belong  to  the  one  condition  from  those 
that  belong  to  the  other.     From  the  nature  of  the  case  they 


2Pottenger:  The  Effect  of  Tuberculosis  on  the  Heart,  Archives  of  Internal  Medicine, 
vol.  iv,  1909. 

displacements  of  the  Heart  and  Diaphragm  Together  With  Disturbances  in  the  Func- 
tion of  the  L,atter  as  Causes  of  Symptoms  in  Pulmonary  Tuberculosis,  Interstate  Medical 
Journal,   1911,  vol.  xviii,   no.   6. 


EFFECT  OF  DISPLACEMENT  OF  HEART  293 

would  be  those  which  belong  to  the  group  of  cardioneurotic 
symptoms  such  as  weakness,  lack  of  endurance,  slight  dyspnea, 
dizziness,  faintness,  disturbed  appetite,  nausea,  and  increased 
pulse  rate.  When  these  changes  are  occurring  the  patient  can 
be  kept  comfortable  by  remaining  at  rest  as  all  of  the  symptoms 
are  increased  on  exertion.  Low  blood  pressure  is  probably  an 
important  etiological  factor  in  this  chain  of  symptoms. 

Displacements  of  the  mediastinum  should  be  looked  for  in  every 
case  of  advanced  tuberculosis  which  has  suffered  the  loss  of 
tissue  to  any  extent.  The  condition  will  often  suggest  itself  to 
the  alert  examiner  when  he  inspects  the  chest,  for  one  side  with 
its  narrow  interspaces  will  be  small,  suggesting  contraction,  and 
the  other  large  and  bulging  with  wide  intercostal  spaces,  sug- 
gesting emphysema.  The  heart  impulse  is  often  visible  and  shows 
either  to  the  right  or  left  of  the  normal  place  for  the  apex.  This 
impulse  must  not  be  taken  as  the  apex.  Very  often  it  is  pro- 
duced by  the  right  ventricle  instead.  Palpation  or  percussion 
will  usually  show  the  deep  borders  of  the  heart  displaced  and 
examination  of  the  larynx  and  trachea  will  show  that  they  are 
drawing  toward  the  side  of  contraction  as  mentioned  above.  The 
second  pulmonary  sound  is  usually  markedly  accentuated  be- 
cause of  the  increased  intrapulmonary  pressure  and  also  because 
the  valve  is  uncovered  when  the  contraction  is  on  the  left.  The 
second  aortic  sound  is  also  often  increased.  But,  on  the  other 
hand,  the  sounds  may  be  weaker  than  normal  when  the  shifting 
is  occurring,  owing  to  the  weakened  condition  of  the  heart  muscle 
at  the  time. 

Compensatory  Changes  in  Thoracic  Cage. — A  discussion  of 
this  subject  would  not  be  complete  without  mentioning  the  part 
taken  in  compensatory  changes  by  the  bony  framework  of  the 
thorax.  Changes  in  contour  of  the  thoracic  cage  are  extremely 
common.  Contraction  occurs  in  one  portion,  expansion  in  an- 
other, and  flattening  is  sometimes  more  or  less  general.  All  of 
these  changes  must  be  looked  upon  as  a  part  of  the  one  ever 
present  scheme  of  maintaining  an  equilibrium  between  the  air 
pressure  without  the  body  and  that  within  the  air  chambers  of 
the  lungs. 

If  the  contractions  which  take  place  in  the  bony  cage  are 


294  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

purely  passive  in  character,  then  we  -would  not  expect  them  to 
occur  except  as  a  last  resort,  after  the  structures  within  the 
thorax  and  abdominal  cavities  had  been  unable  to  make  up  for 
the  tissue  lost.  Given  a  movable  mediastinum  which  presumes 
a  large  non-adherent  pericardium,  permitting  of  easy  and  wide 
movement  of  the  heart;  a  lung  fairly  free  from  disease  on  the 
other  side,  capable  of  taking  upon  itself  a  high  degree  of  com- 
pensatory emphysema ;  and  a  diaphragm  capable  of  moving,  we 
would  not  expect  any  passive  contractions  of  the  chest  wall  until 
these  soft  movable  tissues  had  exhausted  their  capabilities  of 
compensation,  or,  in  other  words,  until  the  force  necessary  to 
compensate  affected  the  bony  framework  rather  than  the  usually 
more  movable  soft  tissues. 

It  must  be  borne  in  mind,  however,  that  the  action  of  the  ribs 
on  the  affected  side  is  not  normal,  not  from  the  time  the  early 
infection  of  the  pulmonary  parenchyma  takes  place.  There  is  a 
shortening  of  the  respiratory  muscles  which  are  renexly  thrown 
into  contraction.  There  is  a  decrease  in  the  elasticity  of  the 
lung  tissue,  and  a  general  limiting  of  the  inspiratory  act  due  to 
the  fact  that  many  of  the  inspiratory  muscles,  including  the  di- 
aphragm, have  their  respiratory  function  renexly  disturbed. 
As  a  result,  the  side  of  the  chest  affected,  does  not  take  its  nor- 
mal part  in  the  inspiratory  act  and  it  becomes  relatively  some- 
what smaller  than  the  other  side. 

It  seems  but  natural  that  the  contraction  of  the  muscles,  which 
exists  for  a  prolonged  time,  should  exert  an  active  force  in 
producing  a  certain  amount  of  compression  of  the  bony  cage.4 
Study  of  the  mechanics  of  respiration  emphasizes  this. 

When  we  see  local  contractions  in  one  portion  of  the  bony 
cage  and  enlargements  in  another,  particularly  when  the  con- 
traction is  confined  to  the  ribs  over  one  lung  and  the  enlarge- 
ment to  those  over  the  other,  we  must  assume  that  certain  ob- 
stacles have  been  met,  and  certain  difficulties  in  establishing 
equilibrium  by  means  of  the  intrathoracic  and  intra-abdominal 
structures  have  presented  themselves  which  could  not  be  over- 
come, and  that  the  bony  cage  has  been  forced  into  the  com- 


4Pottenger:     Muscle  Spasm  and  Degeneration  in  Intrathoracic  Inflammations  and  Light 
Touch  Palpation,  C.  V.  Mosby  Company,  St.  Louis,  1912. 


COMPENSATORY    CHANGES   IN   BONY    THORAX  295 

pensatory  scheme  as  being  the  structure  most  yielding  at  this 
time. 

Such  a  condition  aside  from  the  changes  which  result  from 
muscular  contractions,  to  my  mind,  could  only  exist  when  all 
compensation  possible  had  taken  place  between  the  thorax  and 
abdominal  cavities  and  when  there  was  an  obstruction  to  the 
further  shifting  of  the  mediastinum.  Therefore,  it  would  seem 
probable  that  in  such  cases  the  heart  had  pushed  over  as  far  as 
its  pericardium  would  allow  it  to  push;  and  that  the  enlarged 
lung  was  still  being  enlarged  by  the  atmospheric  pressure,  and 
not  being  able  to  move  further  toward  its  fellow,  and  likewise 
meeting  obstacles  from  below  the  diaphragm,  expended  its 
crowding  force  against  the  ribs  which  at  the  time  offered  the 
least  resistance.  The  principle  that  all  bodies  move  in  the  direc- 
tion of  least  resistance  applies  here,  so  we  cannot  expect  an  en- 
largement of  the  bony  thorax  until  such  a  time  as  this  enlarge- 
ment takes  place  easier  than  enlargement  in  other  directions. 

In  speaking  of  the  bony  cage  being  resistant,  this  must  be  un- 
derstood as  being  in  a  relative  sense  only.  We  recognize  that  the 
contraction  and  enlargement  that  occurs  takes  place  by  de- 
pressing and  lifting  the  ribs  on  their  articulations,  by  changing 
the  angle  of  articulation. 

COMPENSATORY    CHANGES    TAKING    PLACE    BETWEEN 

THE    THORACIC    AND    ABDOMINAL    CAVITIES 

IN  PULMONARY  TUBERCULOSIS. 

This  subject  has  received  but  scant  attention  as  yet  in  medi- 
cal literature;  but  it  is  one  that  demands  more  consideration, 
if  we  are  to  understand  the  circulatory  changes  which  affect 
the  tuberculous  patient  in  any  stage  of  the  disease,  but  particu- 
larly the  one  suffering  from  the  advanced  stage. 

As  the  compensatory  changes  in  the  thoracic  cavity  show  in 
displacements  of  the  mediastinum,  particularly  the  heart,  so  the 
compensatory  changes  between  the  thoracic  and  abdominal  cav- 
ity show  in  displacements  of  the  diaphragm. 

The  Inspiratory  Act. — In  order  to  understand  the  displace- 
ments of  the  diaphragm  it  is  important  to  study  the  function 


296  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

of  this  important  muscle  and  its  relationship  to  the  other  mus- 
cles of  respiration.  I  would  refer  those  who  may  be  interested, 
to  the  writings  of  Hasse,5  Keith,6  Wenckebach,7  and  Eppinger.8 

The  diaphragm  must  be  looked  upon  as  being  the  chief  muscle 
of  respiration  and,  as  such,  it  has  a  very  pronounced  effect  upon 
the  circulation;  for  the  flow  of  blood  toward  the  heart,  and  in- 
directly the  entire  circulation,  is  greatly  influenced  by  the  phases 
of  respiration.  Its  position  differs  according  to  the  age  of  the 
patient,  as  shown  in  Figs.  54,  55,  and  56,  Chapter  XIII. 

Inspiration  is  a  muscular  act  and  takes  place  through  contrac- 
tion and  sinking  of  the  central  tendon  of  the  diaphragm  innervated 
by  the  phrenics  and  a  simultaneous  lifting  of  the  ribs.  The  lifting 
of  the  ribs,  in  quiet  breathing,  is  brought  about  by  contraction  of 
the  intercostales  externi,  the  intercostales  interni  and  the  intercar- 
tilaginei,  supplied  by  the  intercostal  nerves  and  the  levatores  cos- 
tarum  supplied  by  branches  from  the  dorsal  nerves. 

The  lifting  of  the  ribs  in  forced  inspiration  is  aided  by  the 
accessory  muscles  of  respiration.     These  are : 

1.  The  three  scaleni  innervated  by  branches  from  the  cervical 
and  brachial  plexuses. 

2.  Serratus  posticus  superior,  innervated  by  the  dorsalis 
scapula?  from  the  fifth  cervical. 

3.  Sternocleidomastoideus  innervated  by  the  accessorius  and 
branches  from  the  second  and  third  cervical  nerves. 

4.  Trapezius  innervated  by  the  accessorius  and  branches  from 
the  third  and  fourth  cervical  nerves. 

5.  Rhomboidei  innervated  by  the  dorsalis  scapulas. 

6.  The  extensores  columnse  vertebrales  innervated  by  the 
posterior  branches  of  the  spinal  nerves. 

7.  Pectoralis  minor  innervated  by  branches  from  the  anterior 
thoracic  nerves. 

Conditions  which  interfere  with  the  action  of  the  diaphragm 
or  the  first  group  of  muscles  mentioned  will  interfere  with  the 
normal  quiet  respiratory  act;  likewise  conditions  which  inter- 


BDie  Atmung  und  der  venose  Blutstrom,  Archiv  fur  Anatomie  und  Physiologie,  Abt., 
1906. 

6Further  Advances  in  Physiology,  Hill,  London,  1909. 

"Uber  pathplogische  Beziehungen  zwischen  Atmung  und  Krieislauf  beim  Menchen, 
Sammlung  Klinischer  Vortrage   (Volkmann)    Innere  Medizin,  No.    140  and    141,    1907. 

8Allgemeine  und  Spezielle  Pathologie  des  Zwerchfells,  Alfred  Holder,  Wien  und  Leip- 
zig, 1911. 


THE  INSPIRATORY  ACT 


297 


fere  with,  the  diaphragm  and  the  second  group  of  muscles  men- 
tioned will  interfere  with  forced  respiration.  Increased  tone 
(spasm)  or  degeneration  of  these  various  muscles,  by  which  their 
action  is  altered,  such  as  is  present  in  tuberculosis,  or  displace- 
ment of  the  diaphragm  which  is  so  common  in  advanced  tuber- 


^ 


Fig.  43. — Showing  the  movements  of  the  diaphragm  and  thoracic  and  abdominal  walls 
as  well  as  the  change  in  position  of  the  intrathoracic  and  intra-abdominal  viscera  during 
respiration  of  the  thoracic  type.  The  movements  are  from  the  solid  lines  on  expiration 
to  the  broken  lines  on  inspiration.     (Hasse.) 

culosis  interferes  with  inspiration  and  indirectly  exercises  a  del- 
eterious effect  upon  the  flow  of  blood  to  and  from  the  heart. 
The  influence  of  respiration  upon  the  circulation  may  be  under- 
stood by  studying  the  changes  which  occur  in  the  thoracic  and 


298 


COMPENSATORY   CHANGES  IN   TUBERCULOSIS 


abdominal  cavities  during  the  act  of  breathing.  These  can  be 
seen  by  studying  the  accompanying  figures  after  Hasse.  Fig.  43 
illustrates  normal  breathing  of  the  thoracic  type.  The  move- 
ments of  the  various  structures  and  organs  are  from  the  position 


Fig.  44. — Illustrating  the  movements  of  the  diaphragm  and  thoracic  and  abdominal  walls 
as  well  as  the  change  in  position  of  the  intrathoracic  and  intra-abdominal  viscera  during 
respiration  of  the  abdominal  type.  The  movements  are  from  the  solid  lines  on  expiration 
to  the  broken  lines  on  inspiration.     (Hasse.) 

of  the  solid  lines  on  expiration  to  that  of  the  broken  lines  on 
inspiration.  The  entire  chest  wall  anteriorly  and  posteriorly  is 
carried  forward,  the  diaphragm  is  shortened  in  its  anteroposterior 
diameter  and  the  sternum  is  raised  and  pushed  forward.     Fig. 


TYPES  OF  RESPIRATION 


299 


44  represents  the  diaphragmatic  type  of  breathing.  The  walls 
of  the  chest  are  not  moved  to  any  great  degree,  but  the  diaphragm 
pushes  downward  and  the  anterior  and  lateral  walls  of  the  ab- 
domen are  pushed  outward.     In  its  downward  action  the  di- 


Fig.   45. — Showing  the  movements  of  the   diaphragm  and  thoracic  and  abdominal   walls 

as  well  as  the  change  in  position   of  the  intrathoracic  and  intra-abdominal   viscera  when 

combined  thoracic  and  abdo*minal  breathing  are  pronounced.  The  movements  are  from  the 

solid  lines  on  expiration  to  the  broken  lines  of  inspiration.  (Hasse.) 

aphragm  compresses  and  squeezes  the  abdominal  viscera  and  in 
this  way  forces  the  blood  from  the  intra-abdominal  organs.  This 
effect  is  all  the  more  important  because  the  thoracic  cavity  is 
being  enlarged  at  the  same  time  as  the  compressing  force  is  being 


300 


COMPENSATORY   CHANGES  IN   TUBERCULOSIS 


exerted.  Fig.  45  illustrates  the  type  of  combined  thoracic  and 
diaphragmatic  breathing  in  which  the  compressing  abdominal 
force  is  more  than  in  the  thoracic  but  less  than  in  the  diaphrag- 
matic type. 

The  importance  of  the  diaphragm  as  a  muscle  of  respiration 
may  be  inferred  from  Fig.  46,  which  represents  a  sagittal  sec- 


-Q.YUS 


Fig.  46. — Sagittal  section  of  the  body  showing  the  relationship  of  the  diaphragm  to  the 
pericardium,  particularly  showing  the  importance  of  the  crus,  with  its  attachment  to  the 
low  lumbar  vertebrse,  the  contraction  of  which  markedly  enlarges  the  entire  thoracic  space. 
The  crus  is  the  portion  which  secures  its  innervation  from  the  cervical  segments  of  the 
spinal  cord.      (Wenckebach.) 


tion  through  the  body  made  in  such  a  manner  as  to  show  the 
crus  with  its  attachments  to  the  lumbar  vertebrse.  Contraction 
of  this  portion  of  the  diaphragm  exerts  a  very  marked  force  on 
the  abdominal  contents.  When  the  diaphragm  contracts  the  intra- 
abdominal pressure  is  increased  and  the  abdominal  muscles  are 


INSPIRATORY   ACT   AND    CIRCULATION  301 

pushed  outward  carrying  the  lower  central  arch  with  them,  and 
at  the  same  time  other  muscles  of  inspiration  contract  and  raise 
the  ribs.    The  result  of  this  action  is  shown  in  Fig.  47. 

The  effect  of  lessening  the  diaphragmatic  action  is  shown  in 
Fig.  60,  A  and  B,  page  328.  In  A  we  see  that  as  the  diaphragm 
contracts  the  lower  ribs  are  forced  outward  and  the  intrathoracic 
space  is  enlarged.  In  B  we  have  the  motion  of  the  left  half  of 
the  diaphragm  lessened  with  a  resultant  decrease  in  the  normal 
inspiratory  enlargement  of  the  left  side  of  the  chest.  This  con- 
dition is  frequently  met  with  in  pulmonary  tuberculosis  both 
as  a  result  of  reflex  action  through  the  phrenics  and  as  a  result 
of  inflammation  of  the  pleura. 


Fig.  47. — Illustrating  the  movement  of  the  ribs  and  sternum   during  inspiration. 

Inspiratory  Act  and  Circulation. — One  of  the  most  important 
factors  in  the  circulation  of  the  blood,  outside  of  the  heart's  ac- 
tion itself  and  the  elasticity  of  the  vessel  walls,  is  the  suction  ex- 
erted upon  the  blood  column  by  the  thoracic  cavity  during 
respiration.  The  part  of  the  diaphragm  in  this  act  can  be  ap- 
preciated from  the  following  from  Wenckebach  :9  ' '  The  diaphragm 


"Uber    pathologische    Beziehungen    zwischen    Atmung    und    Krieislauf    beim    Menchen. 
Sammlung  klini'scher  Vortrage   (Volkmann)    Innere  Medizin,  No.   140  and   141,   1907. 


302  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

of  mammals  is  the  most  important  factor  in  the  filling  of  the 
heart,  while  in  amphibians  and  the  lower  vertebrates  it  is  the 
only  factor." 

The  pressure  within  the  thoracic  cavity  outside  of  the  air  pas- 
sages is  negative  and  decreased  with  every  inspiration.  The  di- 
aphragm contracts  forcing  the  abdominal  viscera  downward  and 
the  lower  border  of  the  ribs  outward  both  anteriorly  and  later- 
ally, the  other  muscles  of  inspiration  contract  simultaneously 
and  lift  the  ribs,  at  the  same  time  increasing  both  the  antero- 
posterior and  lateral  diameters  of  the  chest!  The  result  in  nor- 
mal respiration  is  a  very  marked  increase  in  the  intrathoracic 
space,  causing  a  markedly  negative  pressure  and  dilatation  of  the 
large  veins  and  chambers  of  the  heart.  During  the  entire  act  of 
inspiration  the  blood  is  being  sucked  in  to  fill  these  veins.  With 
every  expiration,  on  the  other  hand,  the  negative  pressure  dimin- 
ishes, the  veins  and  auricles  become  less  distended  and  the  return 
flow  of  blood  into  the  thorax  is  impeded.  The  intrathoracic  pres- 
sure is  decreased  in  direct  proportion  to  the  depth  of  the  inspira- 
tion, consequently  the  favorable  influence  upon  circulation  likewise 
varies  with  the  depth  of  the  inspiration.  Conditions  which  in- 
crease intrathoracic  pressure  embarrass  the  heart  and  may  prove 
serious. 

The  following  are  the  three  chief  factors  concerned  in  the  dis- 
placement of,  and  disturbance  in  the  function  of,  the  diaphragm 
in  tuberculosis;  the  reflex  stimulation  with  consequent  change  in 
tone  from  the  inflammation  in  the  lung,  not  only  of  the  diaphragm 
itself  through  the  phrenics  but  of  the  other  muscles  of  inspira- 
tion through  their  respective  nerves;  the  loss  of  tissue  and  con- 
traction and  compensatory  emphysema  which  occurs  in  the  lung, 
and  the  alteration  of  the  intra-abdominal  pressure  due  to  the 
wasting  of  the  intra-abdominal  organs  and  the  abdominal  mus- 
cles. These  factors  operating  either  singly  or  jointly,  as  they 
frequently  do  in  tuberculosis,  will  cause  disturbance  in  the  cir- 
culation. 

Not  only  is  an  aspirating  effect  normally  exerted  upon  the 
blood,  sucking  it  into  the  thoracic  cavity  and  heart,  but,  as  the 
diaphragm  contracts  it  increases  the  intra-abdominal  pressure 
and  exercises  a  compressing  force  upon  the  contents  of  the  ab- 


SYMPTOMS   DUE    TO   DEFICIENT   INSPIRATORY   ACT  303 

dominal  cavity  and  actively  squeezes  the  blood  out  of  the  organs. 
A  disturbance  in  the  action  of  the  diaphragm  and  the  accom- 
panying embarrassment  of  the  act  of  inspiration  then  has  a  very 
deleterious  effect.  Failing  to  pump  the  blood  into  the  heart  in 
its  normal  amount,  the  heart  must  accommodate  itself  to  a  rela- 
tively small  amount  of  blood;  also  to  delivering  smaller  amounts 
of  blood  at  each  systole,  the  result  of  which  is : 

1.  A  decrease  in  the  actual  size  of  the  heart. 

2.  A  relatively  smaller  amount  of  blood  in  the  arteries  than 
normal,  thus  producing  a  relative  arterial  anemia. 

3.  A  decrease  in  blood  pressure,  and 

4.  A  storing  up  of  blood  in  the  venous  reservoirs  of  the  body, 
particularly  the  liver,  vena  cava  inferior  and  splanchnic  veins. 

The  small  heart  has  long  been  described  as  being  a  predis- 
posing factor  in  tuberculosis ;  but  it  seems  to  me  to  be  accounted 
for  far  more  satisfactorily  in  this  natural  way. 

Symptoms  Following  Deficient  Inspiratory  Act. — As  a  result 
of  the  storing  up  of  the  blood  in  the  liver  and  splanchnic  veins  we 
have  many  of  the  digestive  disturbances  which  are  so  common 
in  tuberculosis.  This  congestion  interferes  with  the  function 
of  the  organs.  It  causes  the  secretions  to  be  altered,  disturbs 
motility,  favors  intestinal  stasis,  gas  formation,  and  colitis;  and, 
by  retarding  the  blood  and  lymph  movements,  favors  metastatic 
infection.  It  also  interferes  with  the  general  metabolic  activities 
throughout  the  body. 

As  a  result  of  the  various  conditions  which  are  produced  by 
the  disturbance  of  the  function  of  the  diaphragm,  there  is  a  cer- 
tain chain  of  signs  and  symptoms  which  manifest  themselves, 
most  of  which  are  of  the  cardioneurotic  type. 

These  patients  look  pale,  yet,  if  the  blood  is  examined,  the  ex- 
pected change  in  its  constituents  may  not  be  found.  This  is  par- 
ticularly characteristic  of  the  tuberculous  patient,  even  early  in 
the  disease.  "While  we  must  admit  that  anemia  can  and  does  oc- 
cur in  early  tuberculosis,  and  is  often  an  accompaniment  of  late 
tuberculosis,  and  that  tuberculosis  develops  in  anemic  individuals; 
yet  there  is  a  paleness  common,  even  in  the  early  stages  as  well 
as  the  late  stages,  which  is  accompanied  by  little  or  no  change 
in  the  blood  picture.    This  is  accounted  for  by  the  relative  arterial 


304  COMPENSATORY   CHANGES  IN  TUBERCULOSIS 

anemia  which,  results  from  the  reflexly  disturbed  action  of  the 
diaphragm  and  the  other  muscles  of  inspiration,  producing  an 
embarrassment  of  the  inspiratory  act  and  a  consequent  lessening 
of  the  amount  of  blood  sucked  into  the  heart  and  a  diminution  of 
the  amount  delivered  into  the  arteries  at  each  systole.  The  sys- 
temic arteries  being  relatively  empty,  the  patient  appears  pale. 

The  same  condition  accounts  for  the  small  pulse  and  low  blood 
pressure  and  is  another  factor  which  tends  to  increase  the  heart's 
action.  Shortness  of  breath,  lack  of  endurance,  dizziness,  faint- 
ness,  palpitation  and  coldness  of  the  extremities  are  often  com- 
plained of.  Disturbance  in  function  on  the  part  of  the  abdom- 
inal viscera,  such  as  altered  secretions,  disturbed  motility,  colitis, 
flatulence,  diarrhea  and  constipation  are  very  common. 

One  thing  particularly  characteristic  of  the  abdominal  com- 
plications just  mentioned  in  tuberculosis  is  that  they  are  more 
persistent  and  yield  less  readily  to  treatment.  This  is  probably 
due  in  part,  at  least,  in  the  advanced  disease,  to  degenerations 
present  but  also  to  the  constant  congestion  of  the  abdominal  or- 
gans. 

An  unstable  nervous  system  is  another  condition  which  may 
be  traced  to  this  cause,  while  there  is  some  degree  of  neurasthenia 
in  nearly  all  tuberculous  patients,  yet  I  have  noted  that  there 
is  an  unusual  instability  often  present  where  the  diaphragmatic 
disturbance  is  marked.  Especially  is  this  noted  during  the  time 
when  the  disturbance  is  acute.  It  is  remarkable,  however,  to  see 
how  well  nature  can  compensate  for  these  disturbances.  With 
patience  and  encouragement  during  the  time  when  the  destruc- 
tive process  is  going  on  in  the  lung  and  the  compensatory  changes 
are  taking  place,  the  patient  will  usually  arrive  at  a  place  where 
there  is  no  more  shifting  of  the  position  of  the  organs  and  then  a 
remarkable  degree  of  stability  will  be  acquired  and  the  trouble- 
some symptoms  will  disappear. 

In  order  to  comprehend  the  great  importance  of  the  inspiratory 
act  in  aiding  the  circulation  of  the  blood  in  man,  and  to  fully 
grasp  the  part  played  by  the  diaphragm  it  is  but  necessary  to 
study  the  effect  of  the  upright  position  in  animals.  It  has  been 
shown  by  physiologists  that  small  animals  like  the  rabbit  and 
guinea  pig  held  in  the  upright  position  for  a  period  of  time,  are 


DISTURBANCES  IN  POSITION  AND  FUNCTION  OF  DIAPHRAGM        305 

unable  to  maintain  their  circulation;  and  die  of  arterial  anemia. 
Man,  on  the  other  hand,  with  his  well  developed  diaphragm  and 
strong  abdominal  muscles,  is  able  to  overcome  the  effect  of  grav- 
ity and  still  maintain  equilibrium  between  the  venous  and  arterial 
circulation  so  long  as  the  respiratory  act  remains  undisturbed. 
When  this  is  disturbed,  however,  he  is  still  able  to  maintain  the 
circulation  but  with  certain  difficulties  in  the  way. 

Particular  Alterations  in  Position  and  Function  of  the  Di- 
aphragm in  Pulmonary  Tuberculosis. — It  is  probably  within  facts 
to  state  that  the  diaphragm  is  always  disturbed  in  its  function  in 
pulmonary  tuberculosis.  This  disturbance  is  both  reflex  and 
compensatory  in  character,  as  previously  mentioned.  It  is  rarely 
symmetrical,  but  usually  more  marked  on  one  side  than  the 
other.  It  may  be  a  deficiency  in  motion;  it  may  be  a  high  posi- 
tion on  one  side  and  a  low  position  on  the  other ;  a  high  position 
on  both  sides ;  or  a  low  position  on  both  sides.  "When  the  changes 
are  compensatory  in  character  the  position  of  the  diaphragm  de- 
pends on  the  relative  pressures  of  the  thoracic  and  abdominal 
cavities  and  on  the  contractions  and  hypertrophies  which  take 
place. 

In  many  instances  where  marked  displacements  of  the  di- 
aphragm take  place  on  account  of  destructive  change  in  pul- 
monary tissue,  there  is  also  a  serious  wasting  in  the  tissues  in 
the  abdominal  cavity  together  with  a  weakening  of  the  abdom- 
inal muscles.  This  wasting  tends  to  lower  the  intra-abdominal 
pressure  and  also  permits  the  abdominal  organs  to  assume  a 
lower  position  in  the  abdomen  (enteroptosis).  At  the  same  time 
it  takes  away  from  the  diaphragm  one  of  the  chief  forces  in  main- 
taining its  normal  position.  Likewise  the  diaphragm  loses  its 
power  of  expressing  the  blood  from  the  abdominal  organs.  Its  ac- 
tion is  sometimes  disturbed  by  adhesions  in  the  costal  angle. 

Resulting  from  such  conditions  we  often  see,  instead  of  the  nor- 
mal outward  motion  of  the  lower  ribs  anteriorly  and  laterally,  a 
drawing  in  with  every  inspiration.  This  is  often  only  on  one  side, 
sometimes  on  both.  The  effect  is  greatly  to  embarrass  the  cir- 
culation. The  aid  normally  due  the  circulation  from  widening 
the  lower  portion  of  the  thoracic  cavity,  is  taken  away  and  a  nar- 
rowing is  substituted  for  it.    At  times  the  diaphragm  is  so  low 


306  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

that  the  heart  hangs  suspended  from  the  large  vessels  at  the 
base,  as  mentioned  above. 

A  high  position  of  the  diaphragm  as  we  usually  meet  it,  is 
connected  with  an  increase  of  fat  deposited  in  the  mesentery, 
gas  in  the  gastrointestinal  tract,  or  some  tumor  mass  in  the  ab- 
dominal cavity. 

The  symptoms  produced  by  it  are  not  as  serious  for  the  cir- 
culation as  those  produced  by  a  downward  displacement.  In  tu- 
berculosis, however,  we  have  other  conditions  present,  such  as 
the  lowered  intra-abdominal  pressure,  the  weakened  abdominal 
muscles  and  the  pathological  changes  in  the  thoracic  cavity,  so 
the  situation  is  different ;  and  it  must  also  be  looked  upon  as  being 
a  condition  extremely  detrimental  to  a  full  and  free  respiration 
and  as  having  an  embarrassing  influence  on  the  circulation. 

Splanchnic  congestion  favors  acidosis  by  causing  stagnation 
of  the  blood  column. 

Lessened  abdominal  pressure,  caused  by  laxness  of  the  tis- 
sues, reduced  inspiratory  act  and  weakened  abdominal  muscles, 
is  followed  by  cerebral  anemia,  producing  headache,  dizziness, 
muscular  weakness,  and  general  symptoms  of  nervousness. 

It  is  of  great  interest  to  see  how  far  nature  will  go  in  her 
efforts  at  compensation.  In  Fig.  40,  page  286,  I  show  a  wonderful 
compensation  in  which  nature  practically  formed  a  new  lobe  to 
the  lung  and  pushed  it  far  over  into  the  right  thoracic  cavity 
to  fill  the  space  rendered  vacant  by  a  destructive  process.  In 
the  same  case  I  mentioned  how  a  new  lobe  was  made  to  the  liver 
which  pushed  far  up  into  the  thoracic  cavity  to  occupy  the  space 
which  could  not  be  filled  by  the  thoracic  viscera.  In  this  con- 
nection I  would  cite  the  ideas  of  Professor  Tandler  of  Vienna, 
who  speaks  of  the  liver  as  a  compensatory  organ  being  able  to 
enlarge  to  occupy  space  rendered  vacant  by  loss  of  tissue. 

From  the  foregoing  description  of  compensatory  changes 
which  take  place  in  pulmonary  tuberculosis  it  is  evident  that  the 
symptoms  produced  by  them  are  varied  in  nature,  and  that  they 
may  be  on  the  part  of  the  respiratory  system  itself,  or  the  circu- 
latory, nervous  or  digestive  system. 

Effect  of  Arterial  Hypotension  and  General  Wasting  of  Tis- 
sues Upon  Body  Activities. — Hypotension  to  my  mind  is  an  im- 


EFFECT   OF  HYPOTENSION  307 

portant  factor  in  the  general  depressed  state  of  these  patients. 
This  has  usually  been  thought  due  to  the  toxemia,  but  I  be- 
lieve disturbances  in  the  diaphragm  an  equally  important  factor.10 
The  disturbance  on  the  part  of  the  diaphragm  comes  early  and 
lasts  as  long  as  activity  is  present  if  the  case  be  an  early  one;  and 
becomes  permanent  in  all  cases  where  destructive  changes  in  the 
lung  or  pleural  adhesions  at  the  base  result.  In  the  case  of 
the  advanced  disease,  the  factors,  such  as  general  wasting,  de- 
generation of  the  heart  in  particular,  and  displacements  of  this 
organ,  are  added  to  the  toxemia  and  circulatory  changes  caused 
by  the  disturbance  of  the  diaphragm  and  coincident  respiratory 
embarrassment. 

The  pulse  in  quiescent  advanced  tuberculosis  where  the  heart 
is  fully  competent  is  not  far  from  normal  as  long  as  the  patient 
is  at  rest  or  even  under  light  exercise,  unless  large  amounts  of 
the  pulmonary  tissue  have  been  destroyed.  If  more  strenuous 
work  is  engaged  in,  however,  the  heart  is  apt  to  fail  to  measure 
up,  because  it  is  already  working  under  strain  and  on  its  reserve 
power.  The  pulse  increases  to  a  greater  rate  than  would  be  nor- 
mal for  the  work  done  and  fails  to  return  to  the  normal  within 
the  proper  time  limit. 

Where  larger  amounts  of  lung  tissue  have  been  destroyed  the 
patient  may  still  be  comfortable  at  rest;  and  yet  not  be  able  to  do 
any  exercise  without  manifesting  respiratory  embarrassment, 
the  pulse  being  rapid,  dyspnea  appearing,  the  patient  feeling 
weak,  dizzy  or  faint.  The  reason  for  this  is  clear.  The  patient 
is  ordinarily  using  up  all  of  bis  reserve  heart  power  and  still 
is  having  difficulty  in  maintaining  an  efficient  circulation.  As 
long  as  he  is  at  rest  the  functions  of  the  body  are  carried  on 
economically  as  a  minimum  of  energy  is  demanded.  But,  when 
exercise  is  attempted  and  more  blood  is  demanded  the  patient's 
heart  cannot  measure  up  to  the  emergency,  neither  can  the  blood 
be  forced  from  the  splanchnic  reservoir  where  it  is  stored ;  conse- 
quently the  symptoms  follow.  The  flow  of  blood  is  four  or  five 
times  as  rapid  in  active  muscles  as  in  resting  muscles.  Rising  to 
a  position  ready  for  walking  doubles  the  requirements  of  oxygen 

10Enteroptosis  and  Altered  Function  of  the  Diaphragm,  Resulting  from  Intrathoracic 
Inflammations,  New  York  Medical  Journal,  December  16,  1911;  and  Blood  Pressure  in 
Pulmonary  Tuberculosis,  New  York  Medical  Journal,  August  31,  1912. 


308 


COMPENSATORY   CHANGES  IN   TUBERCULOSIS 


compared  with  a  resting  position ;  and  starting  to  walk  quadruples 
it.  The  heart  in  its  weakened  condition  and  its  unnatual  posi- 
tion, with  the  changes  in  the  arterial  walls,  and  the  blood  stored 
up  in  the  veins,  cannot  meet  the  circulatory  requirements. 

While  many  of  these  factors  cannot  be  removed,  yet  there  is 
something  that  can  be  done.  The  heart  cannot  be  wholly  relieved, 
the  arteries  cannot  be  changed,  the  respiratory  movements  can- 
not be  restored,  but  the  intra-abdominal  pressure  can  be  in- 
creased to  a  certain  extent  by  properly  applied  adhesive  straps  or 
suitable  abdominal  binders  so  that  the  venous  stasis  will  be  some- 
what relieved  and  the  onflow  of  blood  to  the  heart  hastened.  In 
this  manner,  circulatory  embarrassment  in  advanced  tubercu- 
losis can  be  greatly  relieved.  An  increase  of  fat  in  the  mesentery 
in  such  cases  is  very  desirable  and  the  greatest  relief  is  experi- 
enced by  increasing  the  patient's  nutrition  to  the  point  of  put- 
ting on  weight. 

The  following  case  illustrates  a  very  marked  degree  of  com- 
pensation and  the  symptoms  which  arise  as  a  result  of  it: 

Case  2414. 

Housewife,  age  32.     Entered  the  sanatorium  February  27,  1914. 

Personal  History. — During  childhood  suffered  from  diphtheria,  scarlet 
fever,  typhoid  fever,  smallpox,  and  measles. 

Tuberculous  History. — Five  or  six  years  prior  to  the  time  of  entering 
the  sanatorium  the  patient  suffered  from  left-sided  pleurisy.  Two  and  a 
half  years  later  she  had  a  diagnosis  of  tuberculosis  made,  by  the  finding 
of  bacilli  in  the  sputum.  She  was  sent  to  Denver  in  July,  1912,  where  she 
remained,  until  the  time  that  she  entered  the  sanatorium,  with  the  excep- 
tion of  one  month  which  she  spent  in  Phoenix.  Two  years  prior  to  the 
time  of  entering  the  sanatorium  she  was  having  what  were  considered 
as  "colds."  These  were  protracted  and  she  had  some  hoarseness  and 
cough.  These  were  accompanied  by  sputum  which  showed  bacilli.  She 
also  suffered  at  that  time  from  night-sweats,  malaise,  lack  of  endurance, 
and  impaired  digestion.  Her  temperature  had  been  irregular.  At  times  it 
had  been  as  high  as  101°.  Her  symptoms  may  be  grouped,  according  to 
their  etiology,  as  follows: 


Those  Due  to  Toxemia. 


Malaise 

Lack  of  endurance 

Digestive  disturbances 

Increased  pulse  rate 

Night  sweats 

Fever 


Those   Due   to   Reflex 
Cause. 


Hoarseness 

Cough 

Pain  in  shoulder 


Those  Due  to  Tubercu- 
lous Process  per  se. 


Frequent  and  protracted 

colds 
Pleurisy 
Sputum — bacillus-bearing 


CASE  ILLUSTRATING  MARKED   COMPENSATION  309 

Physical  Examination. — Physical  examination  made  at  the  time  of  en- 
tering the  sanatorium  showed  a  widespread  disease  affecting  the  entire 
left  lung  and  the  upper  portion  of  the  right.  Infiltration  was  very  dense 
in  the  upper  portion  of  the  left  side  and  there  were  many  rales,  indicative 
of  necrosis,  throughout  the  entire  lung.  There  was  also  evidence  of  cavity. 
There  was  blowing  expiration,  whispering  voice,  together  with  medium 
rales,  metallic  in  character,  near  the  apex  posteriorly.  On  the  right  side 
many  rales  were  also  present,  indicating  that  the  disease  in  this  lung  had 
also  gone  on  to  ulceration.  The  left  lung  had  contracted  markedly,  and 
the  mediastinum  had  shifted  toward  the  left  side.  The  left  border  of  the 
heart  was  in  the  nipple  line  and  the  right  border  was  near  the  middle  of 
the  sternum.     The  right  lower  lobe  was  emphysematous. 

Course  of  Disease  During  Treatment. — The  course  of  the  disease  in  this 
patient  has  been  one  of  continuous  destruction  on  the  left  side  and  steady 
improvement  on  the  right.  This  patient  has  been  under  observation  for 
thirty  months,  and  at  the  present  time  the  function  of  the  entire  left  lung 
is  destroyed.  The  upper  lobe  is  replaced  by  cavity.  There  is  also  ex- 
tensive excavation  in  the  lower  lobe,  and  the  portion  which  remains  is 
fibrous  in  character.  The  disease  in  the  right  lung  has  healed  and  the 
entire  lung  is  emphysematous.  Almost  continually  during  the  thirty  months 
of  observation  this  patient  has  had  some  rise  in  temperature.  At  no  time 
has  she  been  free  for  more  than  a  few  days.  She  also  had  fever  for 
many   months   before    coming  under  my   care. 

I  wish  to  illustrate  by  this  case  one  of  the  most  remarkable  compensa- 
tions that  I  have  ever  observed  in  tuberculosis;  and,  at  the  same  time, 
detail  the  symptomatology  which  results  from  the  pulmonary  destruction, 
the  shifting  of  the  mediastinum,  and  the  shifting  of  the  diaphragm.  I 
shall  attempt  to  describe  this  by  first  giving  the  physical  examination  of 
the  patient  at  the  present  time;  second,  by  a  description  of  the  symptoms, 
as  they  have  been  found  throughout  the  course  of  the  disease. 

Present  Condition  of  Physical  Examination. — Inspection. — On  inspection 
we  find  the  patient  in  a  high  state  of  nutrition.  Contrary  to  what  would 
be  expected,  there  is  only  a  slight  degeneration  of  the  soft  tissues  recog- 
nizable. The  muscles  and  subcutaneous  tissue  on  the  left,  both  anteriorly 
and  posteriorly,  appear  to  be  somewhat  wasted  as  compared  with  those 
on  the  right.  The  left  side  of  the  chest,  as  a  whole,  is  also  somewhat 
smaller  than  the  right.  The  motion  at  the  base  is  limited  on  the  left 
and  exaggerated  on  the  right.  A  pulsation  can  be  seen  in  the  upper  por- 
tion of  the  left  lung,  extending  from  the  first  interspace  down  into  the 
axilla. 

Palpation. — Palpation  confirms  a  slight  wasting  of  the  muscles  and  sub- 
cutaneous tissue  on  the  left  side,  as  compared  with  the  right.  It  also  con- 
firms the  fact  that  the  left  side  of  the  chest  is  somewhat  smaller  than 
the  right.  It  shows  the  diminution  of  respiratory  motion  on  the  left  and 
increased  motion  on  the  right.  Aside  from  this  the  trapezius  and  leA^ator 
anguli  scapulae  show  slight  spasm. 

Palpation  of  Total  Density. — On  deep  palpation  we  find  that  the  upper 
and  outer  portion  of  the  left  lung  is  separated  from  the  chest  wall 
by  the  heart,  which  is  pushed  firmly  against  the  upper  and  inner  axillary 
aspect    of    the    bony   thorax,    there    being    almost    no    space    between    the 


310  COMPENSATORY   CHANGES  IN   TUBERCULOSIS 

mediastinal  contents  and  the  upper,  inner  aspect  of  the  thoracic  cage.  The 
apex,  or  that  part  of  the  heart  which  produces  the  impulse  against  the 
chest  wall,  presents  high  in  the  axilla,  in  the  fifth  interspace.  The  right 
border  of  the  heart  lies  fully  one  inch  to  the  left  of  the  sternum.  The 
lower  portion  of  the  left  lung  is  fibrous  and  there  is  no  air  containing 
tissue  below  the  heart.  The  diaphragm  is  drawn  up.  Posteriorly,  from 
the  apex  to  the  lower  angle  of  the  scapula,  there  is  an  absence  of  resist- 
ance, indicative  of  cavity.  This  takes  in  most  of  the  portion  of  the  lung 
above  the  lower  angle  of  the  scapula.  Near  the  lower  angle  of  the  scapula 
there  is  a  marked  resistance,  suggestive  of  dense  fibrous  tissue;  but  no 
air  containing  tissue  can  be  found  below  this  point. 

On  palpating  over  the  right  lung,  increased  tension,  but  decreased  re- 
sistance is  found  throughout.  This  is  also  found  to  extend  beyond  the 
center  of  the  thorax  to  a  line  perpendicular  with  the  left  nipple  showing 
that  the  right  lung  pushes  over  to  the  middle  of  the  left  thoracic  cavity. 
Palpation  also  shows  that  the  lower  border  of  the  right  lung  has  pushed 
downward  and  fills  in  the  entire  complementary  space.  Posteriorly,  the 
right  lung  is  prevented  from  extending  beyond  the  median  line  by  the 
posterior  mediastinum;  but  its  inferior  margin  extends  to  the  12th  rib. 

Percussion  and  Auscultation  confirm  these  findings. 

The  condition,  as  observed,  is  schematically  represented  in  the  accom- 
panying Fig.  48,  A  and  B. 

Symptoms. — Aside  from  the  usual  symptoms  which  accompany  chronic 
active  tuberculosis,  this  patient  has  suffered  from  those  which  belong  to 
the  cardioneurotic  group;  thus,  tiring,  lack  of  endurance,  exhaustion  on 
the  least  effort,  dizziness  on  assuming  the  erect  position,  dyspnea  on  ex- 
ertion, insomnia,  and  variable  appetite.  These  symptoms  are  indicative 
of  an  inability  of  the  patient  to  furnish  an  adequate  amount  of  blood  for 
the  body  activities.  The  blood  pressure  in  this  patient  is  very  low,  be- 
ing in  the  nineties,  and  has  been  found  below  ninety.  She  has  a  very 
pronounced  splanchnic  congestion;  her  heart,  while  not  markedly  rapid 
when  at  rest,  is  quite  rapid  on  exertion.  As  long  as  this  patient  retains 
the  prone  position  her  functions  are  carried  on  fairly  well;  but,  as  soon 
as  there  is  an  extra  demand  made  upon  her,  as  by  exertion,  she  is  unable 
to  supply  the  extra  blood  that  is  required;  consequently,  she  suffers  from 
the  symptoms  mentioned  above.  When  she  assumes  the  erect  position  she 
has  a  cerebral  anemia,  which  causes  dizziness  and  a  feeling  of  faintness. 

It  will  be  seen,  from  the  examination  findings  above,  that  this  pa- 
tient's diaphragm  is  working  at  a  disadvantage.  On  the  left  side  it  has 
assumed  a  very  high  position,  and  on  the  right  side  a  very  low  position, 
consequently  the  force  of  the  inspiratory  act  is  very  much  diminished. 
Eesulting  from  this  diminution  of  the  inspiratory  act,  the  venous  reser- 
voirs throughout  the  body  are  in  a  state  of  engorgement,  while  the  ar- 
terial system  is    deficient  in  blood. 

Another  factor  which  operates  to  increase  the  relative  splanchnic  con- 
gestion is  the  lowered  intra-abdominal  pressure,  due  to  enlargement  of 
the  cavity  by  the  high  position  of  the  diaphragm  on  the  left  side.  While 
this  is  compensated  to  a  great  extent,  by  the  low  position  on  the  right, 
it  is  not  fully  compensated;  consequently,  there  is  a  deficiency  in  sub- 
stances within  the  abdominal  area,  which  results  in  lessened  pressure,  and, 


Fig.  48. — Showing  schematically  the  compensation  which  has  taken  place  between  the 
two  sides  of  the  chest,  and  between  the  thoracic  and  abdominal  cavities.  A,  anterior  view; 
B,   posterior   view. 


CASE  ILLUSTRATING  MARKED  COMPENSATION  311 

consequently,  lessened  tone  of  the  vessels.  Normal  exercise  calls  for  an 
extra  amount  of  blood,  and  this  is  supplied  from  the  venous  reservoirs, 
particularly  those  in  the  splanchnic  area.  Now,  owing  to  the  deficient 
inspiratory  power  possessed  by  this  patient,  she  is  unable  to  aspirate  the 
blood  from  the  veins  into  the  right  heart  and  furnish  the  required  blood, 
consequently  she  suffers  from  a  lack  of  endurance,  an  inability  to  per- 
form physical  work  and  dyspnea. 

Treatment. — The  respiratory  equilibrium  of  this  patient  cannot  be  re- 
stored. The  functional  capacity  of  the  diaphragm  will  always  be  limited. 
The  splanchnic  congestion  is  more  or  less  permanent;  yet,  there  are  certain 
things  which  can  be  done  which  will  partially  restore  the  circulatory  equilib- 
rium in  this  patient,  and  give  her  a  fair  degree  of  endurance.  This  must 
come  about  through  strengthening  of  the  muscles  of  the  body,  depositing 
a  certain  amount  of  fat  in  the  abdominal  cavity,  and  increasing  intra- 
abdominal tension.  Exercise  would  aid  this  patient  by  strengthening  the 
body  muscles  and  affording  firmer  support  for  the  vessels.  This  is  difficult 
of  attainment  in  this  case  because  there  is  often  a  slight  rise  of  temperature 
present,  so  that,  as  soon  as  we  make  a  certain  amount  of  headway  through 
exercise,  she  is  compelled  to  assume  the  prone  position  again. 

Such  patients  must  be  kept  in  good  nutrition  for  the  intra-abdominal  fat 
is  desirable;  yet  this  must  not  be  carried  too" far  for  it  will  increase  dyspnea 
and  flabbiness. 

Another  feature  of  value  in  cases  such  as  this  is  an  abdominal  support, 
which  will  increase  intra-abdominal  pressure.  These  cases  are  not  easy  to 
handle,  and  yet  a  great  deal  can  be  done  for  them.  If  the  activity  of  the 
disease  in  this  case  ceases,  I  think  it  is  probable  that  a  fair  degree  of  en- 
durance may  be  attained.  As  soon  as  better  tone  can  be  obtained  in  the 
body,  and  particularly  the  abdominal  muscles,  this,  if  accompanied  by  in- 
creased intra-abdominal  fat,  and  reenforced  by  an  abdominal  support,  will 
aid  in  pressing  the  blood  from  the  splanchnic  vessels. 


CHAPTER  Xn. 
TRAUMATIC  TUBERCULOSIS. 

The  relationship  of  trauma  to  tuberculosis  deserves  attention. 
The  medico-legal  aspect  of  this  question  at  times  assumes  im- 
portance. Many  cases  of  tuberculosis  have  been  reported  in  litera- 
ture in  which  trauma  is  supposed  to  have  been  the  primary  cause 
of  the  disease.  In  former  times,  when  we  did  not  understand 
the  nature  of  tuberculosis  as  well  as  Ave  do  today,  it  was  more 
difficult  to  determine  the  definite  relationship  between  a  previous- 
ly received  trauma  and  an  active  tuberculosis.  Today,  however, 
knowing  the  nature  of  tuberculosis  as  we  do,  knowing  that  bacil- 
li circulate  in  the  blood  more  or  less  frequently  after  infection 
has  once  occurred;  and  realizing  further  that  implantation  of 
bacilli  may  be  favored  by  a  traumatic  condition;  and,  further, 
realizing  that  an  old  quiescent  focus  might  be  disturbed  in  such 
a  way  as  to  mobilize  bacilli  through  trauma,  we  can  see  that  sev- 
eral different  conditions  might  arise  whereby  there  would  be  a 
direct  relationship  between  the  trauma  and  tuberculosis.  We 
cannot  conceive  of  trauma  itself,  unless  it  be  a  puncture  by  a 
bacillus-infected  instrument,  producing  tuberculosis.  Infection 
must  either  be  present  prior  to  the  time  of  the  trauma,  or  con- 
ditions must  be  produced  as  a  result  of  the  trauma  which  favor 
some  future  implantation. 

To  further  understand  the  relationship  of  trauma  to  active 
tuberculosis,  it  is  necessary  to  bear  in  mind  that  a  very  large 
percentage  of  adults  have  quiescent  foci  of  tuberculosis  within 
the  thoracic  cavity.  They  may  be  in  the  glands  or  they  may  be 
in  the  lung  tissue  itself.  The  postmortem  reports  of  Hart,  re- 
ferred to  elsewhere  in  these  pages,  shoAV  that  more  than  fifty  per 
cent  of  adults  have  tuberculous  infections  in  the  pulmonary 
tissue;  but  by  far  the  greatest  proportion  of  these  will  remain 
quiescent  during  the  life  of  the  patient.  However,  if  disturbed  by 
trauma,  a  quiescent  focus  may  be  caused  to  take  upon  itself  ac- 
tivity, and  produce  clinical  tuberculosis.     The  effect  of  trauma 


RELATIONSHIP  OF  TRAUMA  TO  TUBERCULOSIS  313 

in  mobilizing  bacilli  may  be  readily  appreciated  by  recalling  how 
such  organs  as  the  liver  and  spleen  are  often  raptured  as  a  result 
of  a  blow  over  them. 

As  physicians,  it  is  our  duty  to  understand  this  question  in 
order  that  we  may  be  able  to  render  a  fair  judgment  in  cases 
which  come  to  us  for  an  opinion. 

From  what  has  previously  been  said  it  can  readily  be  under- 
stood that  a  variety  of  conditions  might  arise  whereby  it  would 
be  necessary  to  determine  the  relationship  between  trauma  and 
existing  active  tuberculosis.  The  problem  is  rendered  more  dif- 
ficult because  many  patients  suffer  from  active  tuberculosis  for  a 
prolonged  period  without  having  a  diagnosis  made. 

Trauma  might  be  either  the  actual  cause  of  liberating  bacilli 
from  a  previously  latent  focus  or  of  causing  a  spread  and  in- 
crease in  severity  of  active  disease  which  is  already  present;  or, 
it  may  injure  the  tissues  and  favor  infection  in  a  part  of  the  lung 
tissue  which  had  not  previously  been  infected.  In  each  of  these 
instances  the  trauma  will  stand  in  a  causative  relationship.  In 
the  first,  it  must  be  looked  upon  as  the  precipitating  cause  of 
clinical  tuberculosis.  In  the  other  instances  it  would  be  looked 
upon  as  having  an  influence  in  increasing  the  severity  of  already 
existing  clinical  tuberculosis,  and  not  as  standing  in  the  relation- 
ship of  producing  clinical  disease.  Therefore,  before  determin- 
ing the  relationship  of  trauma  to  an  existing  active  tubercu- 
losis, it  is  necessary  to  know  the  antecedent  history  of  the  pa- 
tient. One  should  know  whether  an  active  tuberculosis  had  pre- 
viously existed.  In  forming  an  opinion  as  to  whether  or  not  a 
previous  clinical  tuberculosis  had  existed,  we  would  be  obliged 
to  base  it  upon  the  presence  or  absence  of  clinical  history  of  some 
previous  attack  of  tuberculosis,  or  a  clinical  history  of  suspicious 
symptoms  immediately  prior  to  the  time  of  injury. 

A  patient  who  had  previously  suffered  from  a  more  or  less 
active  tuberculosis,  but  who  had  attained  a  healing  of  the  same, 
should  be  looked  upon  in  the  same  light  as  a  patient  who  was  pre- 
viously suffering  from  a  quiescent  unrecognized  lesion.  Such  an 
individual  would  be  more  apt  to  be  seriously  injured  by  trauma 
than  an  individual  who  was  suffering  from  a  small  lesion.  If 
the  patient  who  had  previously  suffered  from  clinical  tubercu- 


314  TRAUMATIC    TUBERCULOSIS 

losis,  was  well  and  had  been  free  from  symptoms  for  months  prior 
to  the  injury,  we  would  then  be  compelled  to  look  upon  the 
trauma  as  standing  in  direct  causative  relationship  to  an 
active  lesion  following  injury.  In  this  connection,  however,  we 
must  bear  in  mind  that  lesions  that  are  extensive,  even  though 
healing  has  been  attained,  now  and  then  show  evidence  of  be- 
coming active  again  in  after  years ;  but,  if  activity  had  not  mani- 
fested itself  in  any  clinical  symptoms  or  physical  signs  prior  to 
the  trauma,  we  would  consider  the  trauma  as  being  the  active 
factor  in  the  production  of  the  clinical  disease. 

For  cases  of  active  clinical  tuberculosis  to  be  definitely  as- 
signed to  trauma  as  the  agency  in  their  active  causation,  the 
symptoms  must  appear  promptly  following  the  injury.  The 
spreading  must  take  place  within  the  time  that  implantation  and 
the  development  of  tuberculosis  would  usually  occur, — that  is 
within  a  period  of  a  few  weeks.  In  this  connection  we  must 
realize  that  it  is  possible  for  bacilli  to  be  mobilized  in  small 
numbers  and  produce  very  small  metastatic  foci.  Clinical  tu- 
berculosis might  result  from  such  an  infection,  yet  require  a  con- 
siderable time  for  the  bacilli  to  be  implanted  and  form  new 
metastases;  and,  in  such  cases,  it  might  be  difficult  to  give  an 
accurate  opinion.  In  cases,  however,  where  the  symptoms  show 
themselves  within  a  few  weeks  after  the  injury,  the  relationship 
can  hardly  be  doubted.  That  a  previous  focus  may,  as  a  result 
of  trauma,  assume  activity,  which  results  in  the  escape  and  scat- 
tering of  bacilli  to  new  tissues,  is  entirely  reasonable.  On  this 
point  so  able  an  authority  as  J.  Orth1  makes  the  important  state- 
ment that  crushing  or  concussion  of  the  thorax  might  produce 
such  a  marked  injury  to  the  tissues,  even  those  which  were  not 
lying  immediately  under  the  point  of  trauma,  that  mobilization 
of  bacilli  in  a  quiescent  focus  might  take  place. 

The  truth  of  this  fact  is  impressed  upon  us  in  the  experiments 
which  are  being  reported  from  soldiers  in  the  present  war.  It 
is  not  uncommon  to  find  tuberculosis  follow  immediately  a  gun- 
shot wound  of  the  thorax.  This  can  be  explained  on  the  ground 
that  a  projectile,  in  passing  through  the  pulmonary  tissue,  pro- 


trauma  und  Lungentuberkulose  Vier  Obergutachten  erstattet  von  Geheimrat,  Zeitschrift 
fur  Tuberkulose  und  Heilstatenwesen,  Bd.  xxv,  Heft.  1,  1915. 


RELATIONSHIP  OF  TRAUMA  TO  TUBERCULOSIS  315 

duces  a  trauma  in  tissues  which  have  previously  been  infected, 
and  thus  causes  an  escape  of  the  enclosed  bacilli  with  resultant 
formation  of  new  foci.  This  can  occur  either  in  quiescent  lesions 
or  lesions  that  are  active.  There  is  quite  a  large  percentage  of 
gunshot  wounds  of  the  thorax  which  are  followed  by  active  clini- 
cal tuberculosis. 

I  have  seen  several  cases  of  supposed  traumatic  tuberculosis, 
but,  in  most  instances  the  injury  had  been  received  so  long  prior 
to  the  time  of  the  active  disease  that  no  connection  could  be  estab- 
lished. In  most  instances,  the  disease  was  at  the  apex  while  the 
trauma  had  been  elsewhere.  The  diagnosis  of  traumatic  tubercu- 
losis had  been  made  simply  because  the  patient  had  previously  re- 
ceived an  injury  to  the  chest. 

The  following  case  illustrates  how  injury  to  the  chest,  pro- 
ducing contusion  of  tissues  may  increase  the  symptoms  and  pro- 
duce a  more  rapid  course  in  a  patient  who  was  previously  suf- 
fering from  active  tuberculosis.  Further,  it  will  be  noted,  that 
it  is  quite  probable  that  the  injury  to  the  tissues  in  this  instance 
produced  a  condition  which  favored  implantation  in  a  new  area. 

The  patient  was  a  man  of  about  thirty  years  of  age.  He  re- 
ceived an  injury  by  stumbling  and  falling  on  a  piece  of  iron, 
which  caused  a  fracture  of  the  sixth  rib  on  the  left  side  in  the 
anterior  axillary  line.  The  rib  punctured  the  lung,  and  was  fol- 
lowed by  spitting  of  blood.    Traumatic  pleurisy  followed  at  once. 

I  examined  the  patient  within  two  months  after  the  occurrence 
of  the  hemorrhage,  and  found  a  localized  tuberculous  process 
surrounding  the  point  of  injury.  The  inflammatory  process  was 
the  seat  of  marked  activity,  causing  toxemia  with  rise  of  tem- 
perature. This  patient  had  previously  been  suffering  from  a 
tuberculous  process  of  the  left  apex,  moderate  in  extent,  and 
slightly  active. 

The  weak  point  in  the  argument  in  this  case  is  that  I  had  not 
examined  the  patient  prior  to  the  time  of  his  injury,  and  can- 
not personally  vouch  for  the  fact  that  there  was  not  an  old  lesion 
at  the  point  of  injury.  However,  he  had  been  examined  shortly 
before  receiving  the  injury  by  a  competent  man,  who  found  no 
evidence  of  trouble  at  the  base.  The  fact  that  there  was  an  area 
entirely  free  from  involvement  between  the  lesion  at  the  apex  and 


316  TRAUMATIC    TUBERCULOSIS 

the  more  extensive  one  at  the  base,  together  with  the  fact  that 
the  active  disease  at  the  site  of  the  trauma,  apparently  came  on 
promptly  after  the  injury,  led  me  to  believe  that  this  was  prob- 
ably a  new  localization  in  which  implantation  of  bacilli  had  been 
favored  by  the  contusion  of  the  tissues.  I  am  not  unmindful  of 
the  fact,  however,  that  there  might  have  been  a  small  quiescent 
focus  in  the  tissues  at  the  point  of  injury,  from  which  bacilli 
escaped  as  a  result  of  the  contusion. 

In  this  case,  we  cannot  look  upon  trauma  as  being  a  direct 
cause  of  the  clinical  tuberculosis,  but  we  are  forced  to  the  con- 
clusion that  it  was,  in  all  probabilities,  the  cause  of  the  new  focus 
at  the  base  of  the  lung,  and  its  relationship  to  the  disease  in  ques- 
tion was  one  of  increasing  its  activity  and  hastening  its  progress. 

The  next  case  answers  all  the  requirements  necessary  for  a 
diagnosis  of  traumatic  tuberculosis.  Evidence  is  present  that 
there  was  an  old  lesion  affecting  the  hilus  and  the  apex  of  the 
left  lung.  From  this,  bacilli  were  mobilized  by  the  trauma  re- 
ceived at  the  time  of  the  accident.  Prior  to  the  time  of  the  in- 
jury, the  patient  was  in  perfect  health,  and  gave  no  history  of 
ever  having  shown  symptoms  indicative  of  active  tuberculosis. 
Immediately  following  the  injury,  the  symptoms  of  active  tuber- 
culosis appeared  and  the  diagnosis  was  confirmed  by  the  pres- 
ence of  physical  signs  in  the  chest,  the  x-ray,  and  the  finding  of 
bacilli  in  the  sputum. . 

Case  2966. 

Clinical  History. — Female.  Always  strong  and  robust.  Lobar  pneumonia 
running  typical  course  when  fifteen  years  of  age.  Mumps  during  college 
life.  Operation  on  turbinates  for  occlusion  of  the  nares  two  years  ago. 
Otherwise  no  illness  until,  following  an  automobile  accident  which  occurred 
on  Oct.  20,  1915,  the  patient  was  rendered  unconscious  and  received  severe 
injuries  to  the  lower  right  chest  and  over  the  left  shoulder.  A  slight  hack- 
ing cough  followed  immediately,  apparently  due  to  the  trauma  to  the  pleura. 
This  persisted.  Shortly  thereafter,  about  November  13,  an  x-ray  plate 
showed  fluid  in  the  right  pleural  cavity.  The  patient's  cough  continued 
and  increased.  The  sputum  which  first  appeared  December  1,  examined 
December  6,  1915,  showed  tubercle  bacilli.  Repeated  physical  examina- 
tions showed  distinct  tuberculous  involvement. 

Physical  Examination. — Examination  made  about  six  months  after  the 
accident  showed  the  following: 

The  patient  is  well  nourished. 

Inspection  reveals  somewhat  diminished  motion  at  both  bases,  more  marked 


CASE   ILLUSTRATING    TRAUMATIC    TUBERCULOSIS  317 

anteriorly  on  the  right  side,  owing  to  pleural  inflammation;  but  posteriorly- 
more  marked  on  the  left. 

Condition  of  the  muscles  and  subcutaneous  tissue. — There  is  a  slight  degen- 
eration of  the  subcutaneous  tissue  near  the  hilus  on  the  right  side;  also  slight 
degeneration  of  the  sternocleidomastoideus,  and  upper  portion  of  the  pee- 
toralis.  The  right  sternocleidomastoideus  also  shows  marked  tone.  There  is 
some  question  whether  it  could  be  in  reflex  spasm,  or  be  a  part  of  the  gen- 
erally well  developed  muscular  condition  resulting  from  continuous  use.  The 
left  sternocleidomastoideus,  scaleni,  and  upper  fibers  of  the  pectoralis  show 
marked  spasm.  Posteriorly,  the  left  trapezius,  and  levator  anguli  scapulae 
are  slightly  degenerated,  indicative  of  an  old  lesion.  The  same  muscles, 
with  the  rhomboidei,  are  in  marked  spasm,  indicative  of  new  activity.  Ap- 
parently no  spasm  on  the  right  side  posteriorly. 

Deep  palpation  reveals  an  increased  density  to  the  4th  rib  anteriorly  on 
the  left  and  in  the  region  of  the  hilus  on  the  right.  Posteriorly,  there  is 
an  increased  density  to  the  middle  of  the  scapula  on  the  left  and  in  the  inter- 
scapular region  on  the  right. 

Percussion  on  the  left  shows  slight  dullness  to  the  4th  rib  anteriorly  near 
the  sternum  and  to  the  3rd  rib  toward  the  axillary  line.  There  is  slight 
impairment  near  the  sternum  on  the  right;  posteriorly,  impairment  with 
slight  dullness  to  the  middle  of  the  scapula  on  the  left,  and  in  the  inter- 
scapular region  on  the  right. 

Auscultation  reveals  a  roughened  note  accompanied  by  numerous  medi- 
um and  fine  rales  from  the  apex  to  the  4th  interspace  on  the  left,  more 
marked  near  the  sternum  than  near  the  axillary  line.  No  rales  on  the  right 
side,  but  slightly  altered  breathing  near  the  sternum.  Posteriorly,  there  is 
roughened  breathing,  with  medium  and  fine  rales  extending  to  the  mid- 
dle of  the  scapula  on  the  left  side,  with  altered  breathing  near  the  vertebras 
on  the  right  in  the  interscapular  space.  There  are  a  few  fine  rales  which 
seem  to  be  of  pleural  origin  in  the  lower  right  anteriorly. 

Diagnosis. — Pleurisy  of  traumatic  origin  at  right  base.  Pulmonary  tu- 
berculosis. Thickening  about  the  hilus  of  the  lung  on  the  right,  with  slight 
extension  toward  the  apex.  Old  foci  in  the  upper  portion  of  the  left  lung, 
upon  which  an  active  process  has  been  engrafted,  most  probably  as  a  re- 
sult of  trauma.     Active  tuberculosis  in  the  upper  half  of  the  lung. 

Comment. — The  physical  condition  of  the  patient  prior  to  the  accident; 
the  absence  of  clinical  symptoms;  and  the  fact  that  she  was  able  to  carry 
on  the  difficult  and  strenuous  work  incidental  to  her  professional  life, 
without  even  being  tired,  or  showing  any  other  symptoms  that  might  be 
attributed  to  an  active  tuberculous  lesion,  indicates  that  any  infection 
that  was  present  prior  to  this  accident  was  quiescent.  The  indications, 
however,  are  that  there  was  an  old  hilus  infection  present,  and  also  a  quies- 
cent focus  in  the  apex  of  the  left  lung.  This  is  indicated  not  only  by 
the  character  of  the  breathing  on  auscultation,  but  by  the  degeneration 
of  the  muscles  and  soft  tissues  covering  this  apex.  This  condition,  how- 
ever, is  not  inconsistent  with  good  health,  as  is  shown  by  such  patho- 
logical reports  as  those  of  Hart,  which  show  that  in  all  autopsies  made 
on  adults  dying  of  ordinary  causes,  an  apical  tuberculosis  is  present  in 
more  than  fifty  per  cent.  The  great  majority  of  these  infections  are 
quiescent  and  produce   no   recognizable   symptoms   during  the   life   of   the 


318  TRAUMATIC   TUBERCULOSIS 

patient.  As  long  as  the  patient  remains  in  good  physical  condition,  he 
seems  to  be  free  from  the  danger  of  the  infection  taking  upon  itself 
activity. 

The  clinical  course  of  the  infection,  following  the  accident,  is  extremely 
interesting.  Immediately  following,  there  was  a  traumatic  pleurisy  at 
the  right  base.  There  was  also  a  dry  cough  which,  at  first,  was  thought 
to  be  referable  to  the  pleurisy;  but  the  pleurisy  soon  disappeared,  while 
the  cough  continued  to  increase  in  severity.  The  examination  of  the  chest 
about  the  middle  of  November  revealed  no  physical  signs  of  active  tuber- 
culosis. Such  could  not  be  expected  at  this  early  date  because  an  infec- 
tion resulting  from  an  activity  lighted  up  by  such  an  accident  would 
most  likely  require  a  longer  period  to  produce  recognizable  symptoms  and 
signs.  By  the  first  of  December  the  cough  had  still  increased  in  severity 
and  expectoration  appeared  which,  on  the  6th  day  of  December,  was 
shown  to  contain  tubercle  bacilli.  Physical  examination  at  this  time  also 
revealed  an  active  tuberculous  lesion  in  the  upper  left  lung.  The  whole 
clinical  course  in  this  case  seemed  to  point  definitely  to  the  accident  as 
being  the  cause  of  the  activity. 


CHAPTER  XIII. 

IMPORTANT  ANATOMICAL  AND  PHYSIOLOGICAL  FACTS 
TO   BE   CONSIDERED   IN   MAKING  PHYSICAL   EX- 
AMINATION OF  THE  ORGANS  WITHIN  THE 
THORAX. 

In  the  course  of  time  the  literature  of  any  subject  becomes  a 
mixture  of  truth  and  error  in  spite  of  the  closest  scrutiny.  To 
this  rule,  the  diagnosis  of  diseases  affecting  the  organs  within 
the  thoracic  cavity  is  no  exception. 

Aside  from  the  logical  analysis  of  signs  and  symptoms,  if  we 
would  make  more  accurate  diagnoses  it  is  necessary  not  only  to 
improve  our  technic  of  making  examinations,  but  also  to  gain  a 
more  accurate  conception  of  the  parts  and  organs  to  be  examined. 
This  statement  holds  for  anatomical  and  physiological  as  well  as 
pathological  considerations.  A  familiarity  with  the  following 
points  will  show  some  of  the  common  sources  of  error  in  physical 
examination. 

Projection  of  Lung  on  Anterior  Surface  of  Chest. — From,  the 
midsternum  to  the  acromial  end  of  the  clavicle  above  and  to  the 
external  border  of  the  axillary  fold  lower  down,  is  a  distance  of 
some  six  inches  in  ordinary  chests.  One  must  not  think,  how- 
ever, that  the  underlying  lung  extends  from  the  midsternum  to 
the  acromion  or  the  axillary  fold.  The  external  border  of  the 
lung  is  bounded  by  the  inner  surface  of  the  ribs.  The  inner 
surface  of  the  first  rib  does  not  extend  beyond  the  inner  fourth 
of  the  clavicle ;  the  inner  surface  of  the  second,  not  beyond  the 
inner  third  of  the  clavicle;  and  the  inner  surface  of  the  third, 
not  beyond  the  inner  half  of  the  clavicle,  consequently,  the  an- 
terior surface  of  the  lung  is  small  in  comparison  with  the  entire 
anterior  surface  of  the  chest  wall  as  may  be  seen  in  Figs.  49 
and  50.  The  latter  being  a  frontal  section  gives  a  splendid  idea 
of  the  relative  amount  of  lung  which  presents.  One  should  bear 
this  in  mind  in  making  examinations.     The  ear  or  stethoscope 


320 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


is  near  lung  tissue  only  over  the  inner  third  of  the  interspace  im- 
mediately below  the  clavicle  and  the  inner  half  of  that  next 
lower.  Above  the  clavicle,  the  apex  is  found  between  the  two 
heads  of  the  sternocleidomastoideus,  and  does  not  extend  out 
in  the  supraclavicular  notch  as  is  usually  taken  for  granted. 

Normal  Border  of  Lung's. — The  normal  borders  of  the  lungs 
are  shown  in  Figs.  51,  52,  and  53.  The  apex  of  the  lung  extends 
3  to  5  cm.  above  the  clavicle.  The  lower  borders  are  at  about 
the  same  height  on  the  two  sides.     For  the  man  in  middle  life 


Fig.  49. — Showing  the  relationship  of  the  anterior  surface  of  the  lung  as  confined  by 
the  bony  thorax  to  the  soft  structures  forming  the  anterior  surface  of  the  chest. 

they  are  on  a  level  with  the  sixth  rib  in  the  mammary  line,  the 
eighth  in  the  axillary  line,  the  tenth  in  the  scapular  line,  and  at 
the  junction  of  the  eleventh  rib  with  the  vertebra  at  the  vertebral 
border.    (See  pages  322,  323,  and  324.) 

The  apex  is  the  nearest  the  surface  between  the  two  heads 
of  the  sternocleidomastoideus,  as  before  mentioned.  On  ordi- 
nary quiet  respiration  the  movement  of  the  lower  border  of  the 
lung  is  scarcely  to  be  determined  by  percussion  and  palpation, 
being  only  1  to  2  cm. ;  but  the  difference  between  forced  inspira- 


Lobus 
sup. 
pulm. 
dextr 


xjl: 


Lobus  sup. 
pulmon.  sin. 


Art.    pulmon. 

uricula  sin. 

cordis 

Valv.    bicuspi- 

dalis  u.  Ventr. 

cordis  sin. 
Lobus  inf. 
pulmon.  sin. 


Diaphragma 


Fig.  50. — Frontal  section  through  thorax  of  26-year  old  man.  Section  made  midway 
between  mammary  and  axillary  line.  (Viewed  from  the  front.)  The  thickness  of  the 
soft  tissues  covering  the  lung  may  be  seen  and  their  influence  on  palpation,  percussion, 
and  auscultation  may  be  inferred  from  this  figure.  It  also  shows  the  relationship  of  the 
lungs  themselves  to  the  anterior  surface  of  the  chest  wall.      (Corning.) 


DIAPHRAGM  AT  DIFFERENT  AGE  PERIODS  321 

tion  and  forced  expiration  can  be  readily  determined  for  it 
amounts  from  6  to  10  cm. 

Position  of  Diaphragm  at  Different  Age  Periods. — The  posi- 
tion of  the  diaphragm  varies  with  the  age  of  the  patient.  Figs. 
54,  55,  and  56,  page  324  (Mehnert),  show  the  diaphragm  at 
birth,  at  36  years  of  age,  and  at  72  years  of  age.  In  develop- 
ment, the  diaphragm  comes  from  high  up  in  the  cervical  region 
and  consequently  receives  a  portion  of  its  innervation  from  the 
cervical  portion  of  the  cord;  the  central  portion  being  supplied 
by  the  phrenics  which  take  their  origin  from  the  third  and  fourth 
or  fourth  and  fifth  cervical  segments.  This  fact  is  important 
in  explaining  the  pain  which  is  found  in  the  shoulder  areas  sup- 
plied by  nerves  from  the  third  and  fourth  cervical  segments,  in 
cases  of  diaphragmatic  pleurisy,  when  the  central  portion  of  the 
organ  is  involved.  The  costal  portion  of  the  diaphragm,  on  the 
other  hand,  is  supplied  by  the  lower  six  intercostal  nerves,  which 
also  supply  the  muscles  and  skin  of  the  upper  abdominal  wall. 
This  fact  accounts  for  the  rigidity  and  pain  over  these  parts  in 
diaphragmatic  pleurisy  when  the  costal  portion  is  inflamed. 

Position  of  Sulci  Which  Separate  Lobes. — The  importance  of 
understanding  the  position  of  the  sulci  which  divide  the  lung  into 
lobes  is  not  so  great  in  early  cases  as  it  is  in  more  extensive  ones. 
Tuberculosis  extends  in  the  lung  most  readily  by  forming  metas- 
tases in  lymph  spaces  adjacent  to  the  original  focus;  or  by  metas- 
tatic infection  through  the  bronchi.  Extension  through  lym- 
phatic metastases  is  confined,  for  the  most  part,  to  the  areas 
adjacent  to  the  previous  focus,  and  does  not  readily  leap  from 
one  lobe  to  the  other.  Bronchogenic  infection,  for  the  most 
part,  follows  the  same  course,  but  it  may,  like  hematogenic  in- 
fection also  go  from  one  lobe  to  the  other,  or  from  one  lung  to 
the  other. 

The  divisions  between  the  lobes  is  shown  in  Figs.  51,  52,  and  53. 
Clinically,  the  division  between  the  upper  and  lower  lobe  may  be 
roughly  marked  by  placing  the  hand  upon  the  opposite  shoulder, 
which  throws  the  lower  point  of  the  scapula  out  toward  the 
axilla,  and  drawing  a  line  along  its  inner  border.  This  line  when 
prolonged,  as  in  Fig.  57,  page  324,  roughly  marks  the  division  be- 
tween the  lobes. 


322 


PHYSICAL  EXAMINATION  OF  ORGANS  OP  THORAX 


In  advanced  tuberculosis  the  greatest  destruction  of  pulmo- 
nary tissue  usually  occurs  in  the  upper  lobes,  and  is  followed 
by  contraction.  A  compensatory  emphysema  follows  in  the 
lower  lobe  and  in  the  other  lung,  causing  their  enlargement.  In 
consequence  of  these  changes  there  is  a  shifting  of  the  inter- 
lobular septum,  mediastinum,  and  diaphragm.     It  is  not  infre- 


L0W£R  MARGIN 
OF  LUNG-- 


LOWER  MARGIN 
OF  PLEURA  -- 


OWER  MARGIN 
OF  LUNG 


-LOWER  MARGIN 
OF  PlEDRA 


Fig.  51. — Illustrating  the  normal  borders  of  the  lungs  and  the  location  of  the  interlobular 
septi.     Anterior  view.     (Corning.) 

quent  in  advanced  cases  with  marked  destructive  processes  in 
one  upper  lobe,  to  find  it  contracted  to  a  small  fibrous  mass  and 
the  lower  lobe  anteriorly  pushing  up  toward  the  apex.  Such 
a  case  is  shown  in  Fig.  40,  page  286,  where  the  middle  lobe  is 
shown  as  a  fibrous  string  and  the  lower  lobe  pushed  upward  to 
the  third  rib.    In  this  ease  the  compensation  was  so  great  that 


PERITRACHEAL  AND  PERIBRONCHIAL  GLANDS 


323 


most  of  the  right  side  of  the  chest  on  the  anterior  surface  as  well 
as  the  left  was  occupied  by  the  left  lung. 

The  Projection  of  the  Peritracheal  and  Peribronchial  Glands 
on  Body  Surface. — The  projection  of  the  peritracheal  and  peri- 
bronchial glands  on  the  surface  becomes  of  great  importance 


LOWER  MARGIN 
OF  LUHG 


LOWER  MARGIN 
OF  PLEURA  -- 


Fig.  52. — Illustrating  normal  borders  of  the  lungs  and  interlobular  septi. 
Posterior  view.     (Corning.) 


now  that  hilus  infection  has  assumed  such  great  proportions. 
Fig.  15,  page  94,  shows  the  location  of  the  tracheal  and  bronchial 
lymph  glands  which  are  so  commonly  infected  and  enlarged. 
Figs.  58  and  59  show  that  dullness  due  to  enlargement  of  such 
glands  in  adults  would  be  usually  expected  in  the  interscapular 
spaces  from  the  third  to  sixth  thoracic  vertebrse.    Dullness  from 


324 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


these  glands  is  most  common  in  children,  however,  and  is  found 
higher  than  in  adults.  Mehnert1  shows  the  changed  position  of 
the  bifurcation  of  the  trachea  according  to  age.  At  birth  it  is  at 
the  third  or  between  the  third  and  fourth,  or  at  the  fourth  tho- 
racic vertebra;  at  two  years  of  age  it  is  between  the  fourth  and 
fifth;  at  thirty-five  between  the  fifth  and  sixth;  at  sixty  in  the 
middle  of  the  sixth;  and  at  seventy- two  on  a  level  with  the  upper 
third  of  the  seventh.  The  mediastinal  glands  are  nearer  the  pos- 
terior surface  than  the  anterior,  consequently  are  more  readily 
detected  posteriorly.    Anteriorly,  the  bifurcation  of  the  trachea 


Fig.  53. — Illustrating  the  normal  borders  of  the  lungs  and  the  location  of  the  interlobular 
septi.      Lateral   view.     A,    right;   B,   left.      (Corning.) 

is  usually  given  as  taking  place  on  a  level  with  the  junction  of 
the  second  costal  cartilage  with  the  sternum,  but  from  data  quoted 
above  its  position  must  be  variable.     (See  pages  326  and  327.) 

Muscles  Employed  in  Normal  Respiration. — Inasmuch  as  defi- 
cient motion  of  the  chest  wall  is  a  very  important  and  almost  con- 
stant accompaniment  of  inflammation  in  the  lungs  and  pleura; 
and,  inasmuch  as  some  disturbance  on  the  part  of  the  motion  of 
the  chest  wall  is  usually  found  in  both  active  and  healed  lesions 


*Uber  topographische  Altersveranderungen  des  Atmungsapparates,  Gustav  Fischer,  Jena, 
1901. 


r 


-< 


* 


» 


9 


\ 


/ 


Fig.    54. — Position    of   the   diaphragm   and   intrathoracic   and   abdominal    organs   at 
birth.      Compare   with    Figs.    55    and   56.      (Mehnert.) 


I    * 


.;  <*■ 


Fig.    55. — Position    of    the    diaphragm    and    intrathoracic    and    abdominal    organs    in    adult 
36  years  of  age.     Compare  with  Figs.    54  and  56.      (Mehnert.) 


Fig.   56.- 


-Position   of  the  diaphragm  and   the  intrathoracic   and  abdominal   organs  in   adult 
72  years  of  age.     Compare  with  Figs.   54  and  55.      (Mehnert.) 


Fig.  57. — Showing  the  location  of  the  sulcus  between  upper  and  lower  lobes  as  deter- 
mined by  placing  the  hand  on  the  opposite  shoulder  and  prolonging  a  line  drawn  along 
the   inner  border  of  the  scapula. 


MECHANICS  OP  RESPIRATION  325 

of  the  lung  and  pleura,  it  becomes  important  for  the  examiner 
to  acquaint  himself  carefully  with  the  mechanics  of  respiration 
and  familiarize  himself  with  the  normal  movements. 

The  inspiratory  act  prepares  the  passages  (nose  and  larynx) 
for  the  entrance  of  air  and  enlarges  the  thorax  anteroposteriorly, 
laterally  and  superoinferiorly.  Normal  inspiration  is  produced 
by  the  contraction  of  the  following  muscles : 

1.  Muscles  of  nose  (not  in  quiet  respiration  as  a  rule  in  man) 
innervated  by  nervus  facialis  (seventh). 

2.  Muscles  of  the  larynx — innervated  by  nervi  laryngei  su- 
perior et  inferior  (tenth). 

3.  The  diaphragm  innervated  by  nervi  phrenici  from  the  third 
and  fourth  or  fourth  and  fifth  cervical  segments ;  and  the  seventh 
to  twelfth  intercostals. 

4.  Intercostales  externi  et  intercartilageni  innervated  by  all 
thoracic  segments  of  the  cord. 

5.  Levatores  costarum  longi  et  breves  innervated  by  filaments 
from  the  spinal  nerves. 

The  sinking  of  the  diaphragm  is  the  more  important  factor  in 
the  male  while  the  elevation  of  the  ribs  is  more  important  in  the 
female.  On  forced  inspiration,  however,  all  muscles  are  brought 
into  play  and  the  chest  is  enlarged  in  all  its  dimensions. 

Influence  of  Diaphragm  in  Respiration. — When  sleeping  or  re- 
clining, if  lying  on  the  back,  both  men  and  women  assume  the 
thoracic  type  of  respiration.  When  lying  on  the  side,  on  the 
other  hand,  they  assume  the  abdominal  type.  The  diaphragm  in 
its  innervation  is  reflexly  associated  with  the  sympathetics  which 
supply  the  lung,  the  afferent  impulses  passing  through  the  rami 
communicantes  from  the  superior  cervical  ganglion  to  the  cer- 
vical segments  which  give  origin  to  the  phrenics.  The  com- 
munication between  the  sympathetics  and  the  cervical  nerves 
is  as  follows:  from  the  superior  ganglion  to  the  first  to  sixth 
cervical  nerves;  from  the  middle  ganglion  (or  corresponding 
position  of  the  trunk  when  this  is  absent)  to  the  fourth,  fifth, 
sixth,  and  seventh  cervical  nerves;  and  from  the  inferior 
ganglion  to  the  seventh  and  eighth  cervical  and  first  thoracic 
nerves.  The  efferent  impulses  pass  out  through  the  phrenics  to 
the  diaphragm  and  cause  a  limited  motion  on  inspiration  which 
becomes  a  valuable  sign  in  inflammations  of  the  lung.     It  also 


326 


PHYSICAL  EXAMINATION  OP  ORGANS  OF  THORAX 


becomes  important  because  of  its  influence  in  lessening  the  in- 
spiratory act.  This,  as  shown  elsewhere  (page  301),  lessens  the 
suction  action  which  delivers  the  blood  to  the  heart,  conse- 
quently, delivers  less  blood  to  that  organ  which,  in  turn,  ac- 
commodates itself  to  a  lessened  quantity  and  becomes  smaller. 
From  a  lessened  output  the  arteries  also  contain  less,  showing 


Fig.  58. — Showing  the  position  of  the  bifurcation  of  the  trachea  and  the  peritracheal 
and  peribronchial  glands  projected  upon  the  anterior  surface  of  the  chest  in  a  young 
adult.     (Gerhartz.) 

an  arterial  anemia,  and  giving  a  lower  blood  pressure,  while 
the  veins  are  full,  giving  a  venous  congestion.  This  latter  does 
not  particularly  manifest  itself  in  the  early  part  of  the  disease 
while  methods  for  compensation  are  still  available;  but,  later,  it 
shows  throughout  the  body.  Congestion  of  the  abdominal  ves- 
sels is  especially  pronounced,  for  the  suction  action  of  the  normal 
inspiratory  act  is  lessened,  and  they  are  also  deprived  of  the  full 
compressing  force  of  the  contracting  diaphragm  upon  the  ab- 
dominal viscera.  Wenckebach  has  aptly  compared  the  compres- 


MECHANICS  OP  RESPIRATION 


327 


sing  action  of  the  contracting  diaphragm  upon  the  liver  to  that 
of  the  compression  of  a  hand  on  a  sponge. 

Anything  which  interferes  with  the  inspiratory  act  produces 
the  effect  above  described.  This  may  be  understood  by  Fig.  60A 
and  B.  When  conditions  have  arisen  in  the  chest  which  make 
it  necessary  to  call  the  accessory  muscles  of  respiration  into  use, 
any  influence  interfering  with  their  action  will  also  affect  the 
force  of  the  inspiratory  act.     (See  page  328.) 

Muscles  Employed  in  Forced  Respiration. — The  accessory 
muscles  of  respiration  also  become  very  important  factors  in  the 
diagnosis  of  tuberculosis  because  of  the  fact  that  they  take  their 
nerve  supply  from  the  segments  of  the  cord  which  receive  af- 
ferent impulses  through  the  rami  communicantes  from  the  sym- 


Fig.  59. — Showing  the  position  of  the  bifurcation  of  the  trachea  with  the  peritracheal 
and  peribronchial  glands  projected  upon  the  posterior  surface  of  the  chest  in  a  young 
adult.     (Piersol.) 

pathetics  in  the  inflamed  lung,  the  same  as  just  mentioned  for 
the  diaphragm. 

This  fact  will  be  evident  from  the  following  table  of  accessory 
muscles  of  respiration  and  their  innervation : 

1.  Scalenus  anticus,  medius  and  posticus, — innervated  by  fila- 
ments from  the  cervical  and  brachial  plexuses. 

2.  Serratus  posticus  superior,  innervated  by  nervus  dorsalis 
scapulas  from  the  fifth  cervical  nerve. 

3.  Sternocleidomastoideus    innervated    by    ramus    externus 


328 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


nervi  aceessorii  and  filaments  from  the  second  and  third  cervical 
nerves. 

4.  Trapezius  innervated  by  ramus  externus  nervi  aceessorii 
and  third  and  fourth  cervical  nerves. 

5.  Rhomboidei  innervated  by  dorsalis  scapulae  from  the  fifth 
cervical  nerve. 

6.  Extensores  columnge  vertebralis  innervated  by  posterior 
branches  of  the  spinal  nerves. 

7.  Pectoralis  major,  innervated  by  external  and  internal  an- 
terior thoracic  nerves  from  the  fifth,  sixth,  seventh  and  eighth 
cervical  and  first  thoracic  nerves. 


X'    A 


FF' 


Fig.  60. — Schematic  illustration  of  the  influence  of  the  diaphragm  in  enlarging  the  intra- 
thoracic space.  A,  normal  respiration;  B,  illustrating  the  effect  when  the  movement  of 
one  side  of  the  diaphragm  is  lessened.  The  intrathoracic  space  fails  to  be  enlarged  to  the 
extent   that   motion   of   the   chest   and    abdominal   wall   EF,   in   figure   B,   is   limited. 


8.  Pectoralis  minor,  innervated  by  seventh  and  eighth  cer- 
vical and  first  thoracic  nerves. 

Thus  it  is  clear  that  these  muscles,  together  with  the  dia- 
phragm, are  innervated  by  fibers  from  the  cervical  segments  of 
the  cord  which  are  in  communication  with  and  receive  afferent 
impulses  from  the  inflammation  in  the  lung  through  the  cervical 
sympathetics  and  the  rami  communicantes.  Acute  inflammation 
in  the  lung  is  expressed  reflexly  in  motor;  and  chronic  inflamma- 
tion in  trophic  changes  in  these  muscles  the  same  as  acute  ap- 


SEGMENTAL  DISTRIBUTION  OP  SOMATIC  NERVES  329 

pendieitis  is  expressed  in  a  motor  reflex  in  the  abdominal  muscles. 
It  is  self-evident  then,  that  the  condition  of  these  muscles  offers 
useful  data  upon  which  to  suspect  both  active  and  chronic  intra- 
thoracic inflammations  and  thus  becomes  of  value  in  the  diagnosis 
of  pulmonary  diseases. 

Segmental  Distribution  of  Nerves  to  the  Somatic  Muscles. — 
With  our  ever  increasing  interest  in  visceral  neurology,  we  are 
not  only  led  to  study  the  functional  changes  in  the  internal  vis- 
cera themselves,  but  also  to  determine  the  manner  in  which  dis- 
eases of  the  internal  viscera  are  reflected  in  the  superficial  tissues 
of  the  body.  The  key  to  this  study  lies  in  the  fact  that  the  body 
is  made  up  of  many  different  segments,  and  that  each  portion  of 
the  surface  of  the  body  which  receives  innervation  from  a  given 
segment,  is  also  bound,  by  reflex  paths,  to  the  various  internal 
viscera  which  receive  their  nerve  supply  from  the  same  segment. 

In  order  to  understand  this  we  must  bear  in  mind  the  develop- 
mental relationship  between  the  cells  in  the  spinal  segments  and 
the  cells  of  the  sympathetic  system.  Early  in  the  course  of  evo- 
lution, the  cells  of  the  sympathetic  nervous  system  pushed  out 
from  the  segments  of  the  cord,  and  today  lie  without  in  their  own 
ganglia.  Each  spinal  nerve  receives  its  innervation  from  cells 
which  lie  within  the  cord  itself.  The  cells  which  give  origin  to 
the  sympathetic  fibers  going  to  the  internal  viscera  which  should 
take  their  innervation  from  that  same  segment  of  the  cord,  on 
the  other  hand,  lie  in  the  ganglia  without  the  cord.  There  is 
still,  however,  connector  fibers  which  run  between  the  cells  of 
the  segment  in  the  cord  and  the  cells  in  the  sympathetic  ganglia 
which  have  been  pushed  off  from  that  segment,  thus  preserving 
the  segmental  relationship. 

The  reciprocal  relationship  between  the  viscera  supplied  from 
a  given  segment  and  the  somatic  structures  supplied  by  the  same 
segment  must  ever  be  borne  in  mind.  Any  stimulation,  or  irrita- 
tion of  the  superficial  structures  of  the  body  supplied  by  a  spinal 
nerve,  produces  disturbances  in  the  nerve  cells  of  that  segment 
of  the  cord  from  which  it  takes  its  origin,  and  this  is  transferred 
through  the  connector  fibers  to  the  cells  in  the  corresponding 
sympathetic  ganglion  which  give  origin  to  the  sympathetic  fibers 
supplying  the  internal  viscera.  In  case  of  inflammation,  this  ir- 
ritation of  the  cells  in  the  cord  produces  pathological  change 


330  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

either  temporary  or  permanent,  which  is  reflected  from  the 
somatic  structures  to  the  internal  viscera;  and  conversely,  when 
internal  viscera  are  inflamed,  from  the  internal  viscera  into  the 
somatic  structures. 

If  only  the  paths  of  these  afferent  nerves  can  be  accurately 
worked  out  we  can  then  anticipate  the  localization  of  the  result- 
ant reflex  action. 

From  this  it  can  be  seen  that  every  inflammation  of  an  internal 
organ  produces  an  irritation  in  the  cells  of  that  segment  of  the 
cord  which  is  in  communication  with  it  through  the  sympathetic 
afferent  fibers  and  the  connecting  rami  communicantes ;  and  that 
this  may  be  expressed  in  the  superficial  tissues  in  sensory,  motor, 
and  trophic  disturbances. 

"While  there  are  some  difficulties  in  the  study  of  the  exact 
innervation  of  the  somatic  structures,  there  is  still  greater  dif- 
ficulty in  determining  the  intricate  innervation  of  the  internal 
viscera.  At  the  same  time,  the  whole  scheme  has  been  worked 
out  in  a  manner  to  be  sufficiently  accurate  for  clinical  work. 
There  are  still  many  clinical  observations  to  be  made  and  many 
physiological  facts  to  be  determined.  The  time  is  now  ripe  for 
clinicians  and  physiologists  to  cooperate  and  aid  in  the  working 
out  of  these  phenomena.  For  the  study  of  the  reflex  motor  and 
trophic  phenomena  which  are  seen  when  internal  viscera  are  in- 
flamed, I  append  the  following  table,  prepared  by  Wichmann, 
and  quoted  by  Bechterew2  in  which  the  somatic  muscles,  to- 
gether with  their  segmental  innervation,  are  shown.     . 

Eef erence  to  this  table  will  facilitate  the  understanding  of  the 
various  reflexes  which  are  described  in  the  text,  such  as  the  reflex 
from  the  lungs  to  the  muscles  of  respiration;  that  of  diaphrag- 
matic pleurisy;  intercostal  pleurisy;  tuberculosis  of  the  intes- 
tines ;  and  tuberculosis  of  the  kidney,  each  one  of  which  will  be 
described  under  its  proper  heading. 

I.    Cervical  Roots. 

C  I-H  Deep  neck  muscles. 

C  I-III  Hyoid  muscles. 

C  II  (T-TTT)  Sternocleidomastoideus  (Nervus  accessorius  Willisii). 


2Die  Funktionen  der  Nervencentra,  vol.  i,   Gustav  Fischer,  Jena,   1908. 


Porus  acusticus 
>         externus 


Processus    mastoi-  _ 
deus 

Processus  styloideus     -V 

M.    masseter 1 

M  M.    digastricus    (venter 

posterior)  

M.    splenius   capitis  — 


M.  digastricus  (venter 
Corpus  anterior) 

ossis    hyoideus 


M.   thyreohyoideus 


M.  omohyoideus  (venter 
superior) 


M.  sternohyoideus 


M.   omohyoideus 
Acromion         A   (venter  inferior) 


Clavicula 


Fig.    61. — Showing  muscles   of  the   neck   (side   view).      Sternocleidomastoideus   and   scaleni 
are    of    special    diagnostic    importance.       (Spalteholtz.) 


Fig.    62.— Showing    the    pectoralis.       (Spalteholtz.) 


SEGMENTAL  ORIGIN  OF  SPINAL  NERVES  331 

C  II-IV  Trapezius.     According  to  Gowers,  the  middle  and  lower 

portion  of  this  muscle  is  innervated  through  the  lower 
cervical,  and  even  the  upper  thoracic  segments. 

C  n-Vm  Longus  colli. 

0  III- VI  Scalenus  anticus. 

C  ni-VTH  Scalenus  medius. 

C  IV  (III)  Diaphragma   (Nervus  phrenicus),  Levator  scapulae. 

C  IV-V  Ehomboidei. 

C  V  (VI)  Supra-    and    infra-spinatus,    Teres    minor,    Subscapularis, 

Subclavicus. 

C  V-VI  Biceps  brachii,  Brachialis  (Nervus  musculo-cutaneous). 

0  V-VI  I L  Scalenus  posticus. 

C  VE  (V)  Deltoideus    (Nervus    axillaris),    Teres    major,    Pectoralis 

major  (pars  clavicularis),  Coracobrachialis. 

C  VI- VII   (V)        Serratus  anticus  major;  Supinatores  (Nervus  radialis). 

C  VI-VEH  Latissimus  dorsi. 

C  VII  (VI)  Triceps  brachii  (According  to  Oppenheim  the  triceps  cen- 

ter lies  lower  in  the  cord),  Eadialis  externus,  Ab- 
ductor pollicis  longus  (Nervus  radialis),  Eadialis  in- 
ternus,  Pronator  teres  (Nervus  medianus),  Musculi 
thenaris  (whose  center,  according  to  other  observers, 
also  lies  lower  in  the  cord). 

C  Vn-VHI  Extensores  digitorum,  Ulnaris  externus  (Nervus  radialis), 

Pectoralis  major  and  minor. 

C  VIII  (VII  Flexores  digitorum,  Pronator  quadratus,  Palmaris  longus 

Th.  I)  (Nervus  medianus). 

C  VTII-Th.  I  Ulnaris  internus  (Nervus  ulnaris).     The  small  muscles  of 

the  hand,  with  the  exception  of  the  thumb,  in  so  far 
as  these  are  innervated  through  the  median  nerve, 
belong  to  a  higher  segment. 

II.    Thoracic  Roots. 

Serratus  posticus  superior. 

Intercostals. 

Eectus  abdominis,  Obliquus  abdominis  externus. 

Transversus  abdominis,  Obliquus  abdominis  internus. 

Serratus  posticus  inferior. 

m.    Lumbar  Boots. 

Psoas,  Cremaster. 

Iliacus. 

Sartorius,  Quadriceps  femoris,  Peetineus,  Adductores  fem- 
oris,  Eectus  internus. 

Obturator  externus. 

Tensor  fasciae  latee  (Nervus  glutseus  superior),  Semimem- 
branosus (Nervus  ischiadicus),  Tibialis  anticus  (Ner- 
vus peroneus). 
L  IV-S  I  Glutei  medius  et  minimus  (Nervus  gluteus  superior)   Ge- 

melli,  Quadratus  femoris   (Nervus  ischiadicus). 


T 

i-rv 

T 

II-XI 

T 

v-xn 

T 

vri-L  i 

T 

rx-xn 

L 

in 

l  n-ni 

L  II-IV 

L 

III-IV 

L  IV-V 

332  PHYSICAL  EXAMINATION  OF  ORGANS  OP  THORAX 

L  V  Semitendinosus    (Nervus  ischiadicus),  Plantaris    (Nervus 

tibialis),  Extensores  digitorum  (Nervus  peroneus). 

L  V-S  II  Gluteus  maximus   (Nervus  gluteus  inferior),  Biceps  fem- 

oris  (Nervus  ischiadicus),  Gastrocnemius,  Soleus,  Tib- 
ialis posticus,  Flexores  digitorum  (Nervus  tibialis). 

IV.    Sacral  Roots. 

S  I  Obturator  internus  (Nervus  ischiadicus). 

S  II  Pyriformis  (Small  muscles  of  the  sole  of  the  foot  with  the 

exception  of  the  abductor  pollicis  and  Extensor  digi- 
torum brevis,  which  belong  to  the  5th  Lumbar  and 
1st  Sacral. 

S  III-V  Muscles  of  generative  organs. 

Influence  of  Muscles  and  Soft  Tissues  on  Physical  Findings. — 

Figs.  61,  62,  63,  and  64,  pages  330  and  332,  show  the  most  important 
neck  and  chest  muscles.  It  is  necessary  for  one  to  familiarize  him- 
self with  them  in  order  to  appreciate  the  influence  which  motor  and 
trophic  changes  in  them  exert  upon  palpation,  percussion  and  aus- 
cultation. 

The  thickness  of  the  soft  tissues  covering  the  lung  varies  over 
different  portions  of  the  chest  wall.  Over  the  pectoral,  scapular 
and  interscapular  regions  it  may  be  one  or  two  centimeters  in 
individuals  with  slight  musculature  or  four  or  five  centimeters  in 
those  in  whom  these  tissues  are  well  developed.  The  apex  of 
the  lung,  posteriorly,  where  covered  by  the  trapezius,  lies  from 
four  or  five  centimeters  to  six  or  eight  centimeters  below  the  sur- 
face. The  influence  of  this  varying  thickness  of  soft  tissues 
upon  the  data  obtained  in  physical  examination  is  extremely 
important. 

It  can  readily  be  understood  that  such  musculature  when  of 
increased  tone  (spasm)  will  afford  different  data  from  what  it 
would  when  normal.  This  can  be  appreciated  particularly  on 
percussion.  It  can  also  be  seen  that,  when  a  degenerative  process 
affects  these  soft  tissues  (skin,  subcutaneous  tissues  and  muscles 
all  degenerate),  as  happens  regularly  in  chronic  tuberculosis,  re- 
sulting in  a  loss  of  substance  at  times  up  to  nearly  half  the  total 
amount,  this,  too,  greatly  modifies  the  data  obtained  upon  phys- 
ical examination.  The  importance  of  the  tone  of  these  soft 
structures  may  be  inferred  from  their  thickness  as  shown  in  Figs. 
65  A,  B,  and  C,  page  334.  This  degeneration  is  all  the  more  impor- 
tant because  it  is  regional  in  character  and  usually  affects  one  side 


Processus  spinosus  vertebrae 
cervicular  VII 


Spina  scapulae 


Acromion 


M.  splenius  capitis 

M.  sternocleidomastoideus 
,M.  trapezius 
Fascia  infraspinatus 


M.  deltoideus 


Processus 
spinosus 
vertebrae 
thoracalis   XII 


M.  triceps 
brachii 


M.  teres  major 


M.   rhomboideus 
major 


"""  M.  latis- 
simus 
dorsi 


Fascia  Iumbodorsalis 
(posterior  layer) 


Fig.  63.— Showing  superficial  muscles  of  the  neck  and  back  (posterior  view).  Trapezius 
of  great  diagnostic  importance.  A  and  B,  portions  of  trapezius  which  show  spasm  and 
degeneration  best.      (Spalteholtz.) 


Protuberantia  occipitalis  . 


Processus  spinosus 
vertebras  cervicalis   VII  y 


M.  semispinalis  capitis 


"M.  splenius  capitis  et  cervicis 

,  M.  levator  scapulae 

»M.  rhomboideus  minor 

/'         ,  M.  rhomboideus  major 
i  Fascia  infraspinatus 
;       M.  supraspinous 
;       '  M.  deltoideus 


Processus  spinosus 
vertebra;  thoracalis  VI 


M.   latissimus 
dorsi 


i  M.  triceps 

M.  teres    M.  teres        brachialis 
major  minor 


Fig.   64. — Showing  the   second  layer   of  muscles   of  the  back.      Levator  anguli   scapula:  and 
rhomboidei    of  special   diagnostic   importance.      (Spalteholtz.) 


OCCUPATIONAL    CHANGES   IN    THORAX  333 

(the  side  of  the  oldest  lesion)  far  more  than  the  other.  The  effect 
on  the  shoulder  girdle  is  shown  schematically  in  Fig.  90,  page  422, 
and  clinically  in  Figs.  95,  A  and  B,  page  466. 

Common  Occupational  Changes  in  the  Soft  Tissues  of  the 
Thorax. — Inasmuch  as  the  condition  of  the  soft  structures  cover- 
ing the  thorax  offers  important  diagnostic  signs  in  pulmonary 
tuberculosis,  it  is  necessary  that  we  familiarize  ourselves  with 
those  things  which  cause  a  departure  from  the  normal.  The 
discussion  of  the  pathological  variations  from  the  normal  will  be 
found  elsewhere  in  these  pages.  In  my  study  of  the  reflex  spasm 
and  degeneration  of  the  muscles,  and  the  degeneration  of  other 
soft  tissues,  caused  by  inflammatory  processes  within  the  lung, 
the  conditions  which  have  caused  me  most  trouble  have  been 
those  due  to  changes  which  result  from  occupational  influences. 

Right-handedness  is  almost  universal.  The  fact,  however,  that 
there  are  a  large  number  of  people  who  are  left-handed,  gives 
us  an  opportunity  to  draw  fairly  accurate  conclusions  from  the 
changes  which  come  from  more  or  less  constant  use  of  one  hand 
in  preference  to  the  other.  We  have  found  that  people  who  use 
their  right  hand  most,  not  only  in  muscular  acts,  but  in  carrying 
objects  as  well,  have  a  lowering  of  the  shoulder  on  that  side,  as 
compared  with  the  other  shoulder.  In  persons  who  are  left- 
handed,  we  find  this  lowering  of  the  shoulder  on  the  left  side. 
This  indicates  that  there  are  certain  changes  which  take  place 
in  the  supports  of  the  shoulder  girdle  on  account  of  constant 
use.  Examination  shows  this  to  be  a  lengthening;  and,  ap- 
parently, at  least,  a  degeneration  of  the  shoulder  muscles,  which 
is  particularly  emphasized  in  the  trapezius  and  levator  anguli 
scapulas.  There  is  also  an  apparent  degeneration  or  thinning 
noted  in  the  peetoralis  on  the  side  of  the  arm  used  most.  This 
lengthening  and  degeneration  of  the  muscles  is  almost  universal 
in  the  human  family,  except  in  those  individuals  who  do  heavy 
work  with  these  muscles.  Such  individuals  very  often  show  a 
marked  hypertrophy  which  almost,  and,  at  times,  wholly,  over- 
comes any  stretching  or  thinning  of  the  muscles  that  would  other- 
wise be  evident. 

Normal  Variation  in  Physical  Types  and  Their  Visceral  Func- 
tion.— An  error  in  both  physical  and  functional  diagnosis  arises 
from  attempting  to  consider  all  individuals  from  a  given  stan- 


334  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

dard.  Such  is  impossible.  Among  other  things,  individuals  dif- 
fer in  general  contour  of  the  body,  in  size,  in  weight,  in  the 
amount  of  flesh,  in  the  shape  of  the  thorax,  in  the  shape  of  the 
abdomen,  in  muscular  strength,  and  nerve  stability.  Of  neces- 
sity, the  organs  must  differ  in  form  and  functional  capacity. 
We  cannot  have  the  same  shaped  lungs,  the  same  shaped  liver, 
the  same  position  of  the  kidneys,  and  the  same  position  of  the 
intestines  in  a  long  slender  body  that  we  have  in  a  short  thick 
body.  Neither  can  we  have  the  same  degree  of  functional  ca- 
pacity and  functional  activity  in  all  individuals. 

There  has  been  too  much  of  a  tendency  to  try  to  measure  all 
individuals  by  the  same  standard.  In  examination  of  the  chest 
a  low  diaphragm  in  one  patient  would  not  be  a  low  diaphragm 
in  another.  The  heart  must  assume  an  entirely  different  posi- 
tion in  a  long  chest  from  what  it  does  in  a  short  chest.  "We 
cannot  judge  the  position  of  the  abdominal  viscera  with  relation 
to  the  umbilicus  in  all  individuals.  The  examiner  must  bear  in 
mind,  therefore,  that  the  organs  must  fit  in  according  to  the 
size  and  shape  of  the  cavity  in  which  they  are  placed.  In  this 
way  only  can  he  learn  departures  from  the  normal.  Clinicians 
must  also  bear  in  mind  that  there  is  no  normal  functional  activity 
for  all  individuals. 

In  discussing  the  functional  activity  of  the  gastrointestinal 
tract,  observers  tell  us  that  the  stomach  should  be  empty  in  six 
hours;  consequently,  we  fix  in  our  mind  that  anything  short  of 
six  hours  is  too  rapid,  and  anything  later  than  six  hours  is  too 
slow.  Such  is  erroneous.  An  individual  with  a  stomach  in  a 
high  state  of  functional  activity  and  strong  musculature  may 
empty  this  organ  in  less  than  six  hours,  without  being  looked 
upon  as  having  hypermotility.  On  the  other  hand,  a  person  with 
a  less  degree  of  functional  activity  with  less  muscular  strength, 
might  require  longer  than  six  hours  and  still  not  suffer  from 
hypomotility. 

Our  conception  of  the  normal  must  be  altered  to  suit  the  phy- 
sical and  functional  capacity  of  the  individual. 

To  simplify  matters,  however,  individuals  may  be  classified  in 
certain  groups  in  which  the  shape,  relationship,  and  functional 
capacity  of  organs  may  be  inferred  from  the  physical  form  and 
degree  of  nerve  stability  of  the  individual. 


Fig.  65A. — Sagittal  section  through  the  body  showing  the  thickness  of  the  soft  struc- 
tures covering  the  apex  from  which  may  be  inferred  the  importance  of  the  increased  tone 
(spasm)  or  degeneration  upon  the  findings  on  palpation,  percussion,  and  auscultation. 
Anterior  view.      (Corning.) 


M.  trapezius. 
M.  omohyoideus. 

M.  supraspinatus. 

A.  mibelavia. 

Costa  I. 

Clavicula. 

Plane  or  Manubrium  Sterni. 

Scapula. 

M.  subscapular^. 

LobuB  Buperior  pulmonis. 

Incisura  interlobaris. 

M.  pectoralis  major. 

Lobus  medius  pulmonis. 

Transthoracic  Plane, 

Lobus  inferior  pulmonis. 
Diaphragm 


Transfyloric  Plane. 
Right  kidney. 

Vesica  fellea.    (Gallbladder.) 
Flexura  coli  dextra.     (Hepatic  flexure. 

Musculature  of  abdominal  parietes. 

Colon  transversum. 

Trans-tubercular  Plane, 

Tntestinum  cecum. 
M.  gluteus  medius. 
Intestinuiii  tenue. 
M.  iliaeus. 
M.  gluteus  minimus. 


Caput  fehioris. 

H.  gllitwufl  inaximus. 


M.  iliopsoas. 
V.  femoralis. 


Fig.  6SB. — Section  through  body  6  cm.  to  the  right  of  the  median  plane,  viewed  from 
the  right.  Showing  the  importance  of  the  soft  tissues  as  influencing  physical  examination 
of  different   areas  of  the  chest.      (Berry.) 


Costa  I. 

Scapula. 


•  Manubrium  Sterna. 


Lobus  superior  pulmonis.- 


IVriiurdium., 
Ventriculus  sinister. 
Transthoracic  Plane. 

Lobus  inferior  pulmonis, 
Diaphragina. 


Pars  cardiaca  vehtriculi.    (Stomach.) 

Glanclula  suprarenalis. 

Left  kidney.  .' 

Corpus  pancreatis„ 

TRANSPYI.ORIC  PLANE. 

Pars  pylorica  ventriculi.    (Stomach.) 
Flexura  duodenojejunalis. 


M.  sacrospinal  is.    (Erector  spince, 


transyersus  lumbar  vertebra, 
51.  psoas  major. 


Musculature  of  abdominal  parietes. 

Transtubercular  Plane. 
Pars  lateralis  ossis  sacri. 
A.  iliaca  comimtnis  sinistra. 


V.  iliaca 


Intestinum  tenue. 

M.  piriformis. 

A.  iliaca  externa  sinistra. 

Ramus  superior  ossis  pubis. 

M.  obturator  internus. 

PLANE  OK  SYMPHYSIS  OsSIUM  PUBIS. 

Membrana  obturatoria. 
M.  obturator  externus. 
M.  glxitieus  maxinius. 
Ramus  inferior  ossis  isehii. 

Adductor  musculature. 


Fig.  65C. — Section  through  body  6  cm.  to  the  left  of  the  median  plane  viewed  from  the 
right.  Showing  the  importance  of  the  soft  tissues  as  influencing  physical  examination  of 
different  areas   of  the   chest.      (Berry.) 


VARIATION   OF  VISCERAL  FORMS  AND   HABITUS  335 

These  facts  have  been  particularly  emphasized  by  the  splendid 
original  work  of  Dr.  R.  Walter  Mills,  'of  St.  Louis.3  Owing  to 
the  extremely  great  importance  of  this  subject  for  all  practi- 
tioners of  internal  medicine,  I  wish  to  append  the  following  orig- 
inal manuscript  prepared  especially  for  this  monograph  by  him. 


THE  RELATION  OF  VISCERAL  FORM,  TOPOGRAPHY  AND 

FUNCTION  TO  THE  GENERAL  PHYSIQUE,  WITH  A 

CLASSIFICATION  OF  TYPES. 

By  R.  Walter  Mills,  M.D. 

If  by  means  of  the  x-ray  any  considerable  number  of  subjects 
are  studied  with  regard  to  the  topography  of  their  thoracic  and 
abdominal  viscera  the  factor  of  individual  variation  becomes  so 
evident  as  to  make  the  futility  of  any  single  topographical  stand- 
ard exceedingly  apparent.  The  massive  body  of  a  heavy  power- 
ful man  houses  a  heart  so  different  in  outline  from  that  of  a 
slender  woman  of  less  than  half  his  height,  as  to  make  them  ap- 
pear almost  as  different  organs.  In  the  same  way  the  general 
outline  of  the  lung  fields,  the  silhouette  of  the  diaphragm,  and 
the  form  and  position  of  the  abdominal  viscera  vary  widely  in 
extremes. 

If  a  series  of  subjects  are  so  studied  as  to  graphically  and 
accurately  reproduce  the  visceral  outlines  in  that  of  the  bodily 
figure,  certain  constancies  as  to  relationship  between  visceral 
forms  and  position  and  the  general  physique  become  apparent; 
for  instance,  that  a  certain  type  of  powerful  massive  individual 
always  houses  a  heart  and  lung  fields  of  characteristic  outline, 
and  that  such  are  never  normally  found  in  other  bodily  types. 

If  the  above  conception  be  true,  there  must  be  controlling  fac- 
tors governing  such  relationship.  It  would  seem  that  there  are 
such  factors.  First  and  chiefly  the  essential  individual  skeletal 
architecture.  The  subject  of  massive  osseous  plan  presents  a 
thoracic  cage  capacious,  deep  in  its  anteroposterior  dimensions, 
wide  in  its  lower  lateral,  and  relatively  short  as  compared  to 

'Observations  on  Duodenal  Ulcer  with  Special  Reference  to  Its  X-Ray  Diagnosis,  In- 
terstate Medical  Journal,  vol.  xxiii,  no.  4,   1916. 


336  PHYSICAL,  EXAMINATION  OF  ORGANS  OF  THORAX 

other  types  in  its  longitudinal  axis.  This  latter  is  influenced  by 
the  arrangement  of  the  abdominal  regional  capacities  as  such  a 
subject  has  a  high  digestive  plant  in  turn  due  to  a  relatively 
small  pelvic  capacity  and  considerable  space  occupying  abdom- 
inal fat.  A  chest  of  such  fixed  regional  capacities  can  only  house 
lungs  of  certain  form. 

The  second  determining  factor  in  the  relationship  of  visceral 
topography  to  bodily  habitus  is  variation  in  the  muscular  tonus 
of  different  persons.  By  tonus  we  understand  that  inherent 
resilience  possessed  in  varying  degrees  by  all  living  muscular 
tissue.  The  muscular  tonus  of  the  alimentary  viscera  is  a 
chief  factor  in  giving  them  their  form;  it  seems  highly  prob- 
able that  the  form  of  the  heart  in  like  manner  may  be  in- 
fluenced by  the  tonus  of  its  musculature.  The  tonus  of  the 
skeletal  muscles  and  intimately  associated  with  it  their  degree 
of  muscular  strength  contributes  to  visceral  form  by  influencing 
the  form  of  the  thoracic  and  abdominal  cavities.  A  skeletal 
musculature  of  a  high  degree  of  tonus  and  strength  makes  for 
integrity  of  the  general  static  poise ;  hence  there  is  less  tendency 
to  spinal  curvature,  figure  collapse,  and  postural  abnormalities. 
Again,  a  well-developed  belly  musculature  is  a  considerable  fac- 
tor in  influencing  the  form  of  the  abdominal  and  secondarily,  the 
thoracic  viscera. 

The  degree  of  nutrition  plays  a  role  in  determining  the 
form  of  the  viscera;  where  poor,  the  abdominal  viscera  are 
lacking  a  considerable  support  in  the  way  of  intra-abdominal 
fat,  and  occupy  a  lower  position  than  in  well-nourished  subjects 
because  the  pelvis  is  more  roomy.  In  turn  the  upper  abdomen 
being  of  lesser  content  is  smaller  and  the  form  of  lung  fields  and 
heart  consequently  influenced  being  of  longer  longitudinal  di- 
mensions. The  degree  of  nutrition  furthermore  modifies  visceral 
form  in  overnourished  subjects  through  its  influence  on  static 
conditions  and  the  form  of  the  abdomen.  A  heavy  pendant  ab- 
domen results  in  a  somewhat  lower  position  of  the  abdominal 
viscera  than  is  normal  for  that  particular  subject  judged  by  the 
general  skeletal  type  with  consequent  influence  upon  the  form  of 
the  thoracic  viscera. 

The  physiological  needs  of  the  individual  influence  the 
form    of   the    viscera.     In   one    of  robust    and   heavy   figure, 


FACTORS  INFLUENCING  VISCERAL   FORM   AND   TOPOGRAPHY       337 

the  heart  must  serve  greater  demands  and  is  consequently 
larger  and  of  a  form  resulting  from  a  heavier  cardiac  muscular 
development.  The  abdominal  viscera  having  to  accommodate 
and  digest  a  larger  amount  of  food  proportional  to  the  metabolic 
needs  of  the  individual  are  of  a  form  favorable  to  a  more  rapid 
alimentary  motility  than  occurs  in  slender  persons. 

All  factors  influencing  bodily  and  consequently  visceral  form 
act  in  varying  degrees  in  the  individual  case  and  frequently  at- 
tain an  extraordinary  complexity  in  the  determination  of  the 
final  visceral  type  and  arrangement.  On  the  other  hand,  one 
factor  may  be  so  dominant  as  to  permit  of  but  little  change  from 
the  essential  plan  even  though  all  others  be  greatly  modified; 
for  example,  a  subject  may  be  primarily  of  so  massive  and 
powerful  a  physique  that  no  alteration  in  those  other  factors 
usually  influencing  visceral  form  serves  to  change  the  plan. 
Muscular  tonus  and  strength  may  be  decreased  through  debility, 
great  loss  of  weight  occur,  and  still  not  greatly  alter  that  essen- 
tial visceral  type  and  arrangement  characteristic  of  such  phy- 
sique. In  that  other  extreme  of  habitus,  the  congenital  type 
having  normally  a  pelvic  digestive  plant,  long  gracile  thorax, 
pendant  heart  and  poor  muscular  tonus,  no  increase  in  fat  or 
artificially  developed  musculature,  no  improvement  in  general 
well  being  serves  to  alter  the  essential  stigmata  of  such  type.  It 
is  in  intermediate  types  of  physique  that  the  balance  between  the 
various  factors  resulting  in  the  individual  visceral  topography 
are  most  delicately  balanced,  so  that  a  marked  loss  in  the  in- 
tegrity of  one  factor  often  results  in  distinct  change  in  form  and 
position.  A  man  may  be  of  average  build,  strength  and  nutri- 
tion ;  in  him  a  marked  deficiency  in  alimentary  tonus  may  result 
in  distinctly  different  alimentary  outlines  from  what  his  general 
physique  would  lead  us  to  anticipate. 

From  what  has  been  said,  it  may  be  gathered  that  the  position 
is  here  taken  that  there  is  no  single  type  of  visceral  form  or 
position  that  may  be  considered  normal,  and  that  all  others  not 
corresponding  thereto  are  abnormal.  We  may  no  more  elect  one 
normal  visceral  standard  than  we  may  elect  one  individual's 
physique  as  a  standard  for  all  persons.  Eather  we  must  hold  that 
innumerable  types  of  physique,  visceral  form  and  topography 
occur  as  a  rule  representing  normal  conditions  and  that  an  ab- 


338  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

normal  status  only  exists  when  there  is  a  gross  departure  from 
the  essential  bodily  plan  of  that  given  individual  as  judged  by 
standards  established  by  studies  of  large  numbers  of  subjects 
of  similar  type. 

In  addition  to  great  variation  in  the  form  and  position  of  the 
viscera  any  extended  observations  of  different  subjects  will 
show  an  equally  wide  variation  in  certain  physiological  processes ; 
perhaps  the  most  striking  being  difference  in  the  degree  of  vis- 
ceral tonus.  Here  too  a  relationship  will  be  found  to  exist  be- 
tween the  general  bodily  habitus  and  the  degree  of  tonus.  In 
those  of  a  certain  type  of  powerful  physique,  the  degree  of  vis- 
ceral tonus  will  be  found  to  be  great,  while  in  those  of  an  oppo- 
site type — asthenics — "congenital  enteroptotics, "  it  is  poorest. 

There  are  before  us  certain  considerations:  First,  an  infinite 
variation  in  bodily  physique,  visceral  forms  and  in  certain  phys- 
iological processes.  The  presence  in  this  great  series  of  varia- 
tions of  certain  dominant  types  of  physique  and  visceral  topog- 
raphy also  well-marked  degrees  of  certain  physiological  pro- 
cesses. A  constancy  of  relationship  between  certain  types  of 
physique,  certain  visceral  forms  and  degrees  of  physiological 
manifestations  is  also  evident.  Second,  a  very  evident  need  for 
more  accurate  standards  by  which  departures  from  normal  con- 
ditions whether  morphological,  topographical  or  physiological 
may  be  judged  in  the  given  case.  This  for  diagnostic  ends  and 
for  purposes  of  study.  A  need  that  it  seems  perfectly  evident 
can  not  be  subserved  by  selecting  one  type  as  normal  and  con- 
sidering all  other  types — consequently  a  majority  of  all  per- 
sons— as  abnormal.  On  the  other  hand  it  is  obviously  impracticable 
to  have  an  individual,  though  in  many  ways  ideal,  standard  of 
anatomy  and  physiology  for  each  person.  Third,  the  possibility 
that  failing  both  a  single  standard  for  all  and  an  individual  stand- 
ard for  each  one,  we  may  through  a  classification  of  types  as  to 
physique  and  their  parallel  visceral  peculiarities  best  serve  our 
ends.  This  we  believe  is  practical  and  while  a  difficult  matter  on 
account  of  the  amazing  complexity  in  which  different  character- 
istics are  often  present  in  the  same  individual,  offers  us  a  basis 
for  further  study  that  is  more  satisfactory  and  hopeful  than  our 
former  one  type  standard. 

An  investigation  of  hundreds  of  individuals  in  whom  the  vis- 


HYPERSTHENIC   HABITUS  339 

ceral  plan  has  been  graphically  recorded  in  its  relation  to  bodily 
contour,  has  shown  that  in  two  extremes  the  relationship  of 
habitus  to  visceral  form,  position,  tonus  and  motility,  is  a  con- 
stant. Since  the  question  of  chest  topography  is  chiefly  of  in- 
terest here,  special  attention  will  be  given  it  though  it  must  be 
emphasized  that  both  thoracic  and  abdominal  topographies  and 
forms  are  commonly  characteristic  of  certain  types  of  habitus 
and  consequently  they  bear  to  each  other  a  definite  relationship. 
In  the  following  descriptions  of  topographical  relations  the  in- 
dividual is  considered  as  in  the  standing  position  with  the 
stomach  filled  to  the  same  degree  as  after  the  standard  bismuth 
meal.  The  first  of  these  two  dominant  types  in  which  the  general 
physical  and  visceral  peculiarities  are  dominantly  characteristic 
has  been  classified  as  hypersthenic  (Fig.  66).  Subjects  of  this 
type  are  of  the  most  powerful  physique  and  usually  very  heavy. 
The  body  framework  is  exceedingly  massive,  the  thorax  deep 
anteroposteriorly,  wide  in  its  lower  lateral  diameters  and  short 
longitudinally.  The  costal  arch  is  so  obtuse  as  to  be  sometimes 
almost  a  straight  line,  giving  the  figure  a  peculiar  gorilla-like 
appearance.  The  pelvis  is  comparatively  small.  Corresponding 
to  the  form  of  the  thorax,  the  lung  fields  are  broad  at  the  base, 
the  general  direction  of  their  lower  borders  approaching  the 
horizontal.  The  lung  fields  contract  markedly  from  base  to  apex 
giving  the  combined  lung  fields  the  form  of  a  truncate  pyramid. 
The  apices  are  small  and  extend  but  little  above  the  clavicles, 
less  so  than  in  any  other  type.  The  form  of  the  heart  being  very 
characteristic  in  the  hypersthenic,  influences  the  outline  of  the 
lungs,  especially  the  left.  The  heart  is  peculiar  in  that  it  occu- 
pies an  almost  transverse  position.  It  seems  largely  below  the 
silhouette  of  the  diaphragm,  giving  an  appearance  of  being  half 
submerged.  Often  the  outline  of  the  left  ventricle  is  almost  a 
continuation  of  the  lower  border  of  the  left  lung  field.  The  out- 
line of  the  aortic  arcus  as  silhouetted  by  the  x-ray  is  short  and 
broad,  and  the  shadow  of  its  apex  projects  less  to  the  left  than  in 
less  sthenic  types.  As  viewed  from  the  front  the  lung  area  ap- 
pears smaller  than  in  other  types,  only  apparently  so  as  the  lungs 
are  much  deeper  than  in  persons  of  slender  habit  and  their  vol- 
ume is  consequently  in  keeping  with  the  size  and  weight  of  the 
body.    Owing  to  the  short  thorax  and  the  long  abdomen  charac- 


340  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

teristic  of  the  hypersthenic  habitus  one  of  the  most  peculiar  fea- 
tures of  the  type  is  the  very  high  digestive  plant,  the  stomach  be- 
ing almost  thoracic  and  the  intestines  especially  high  in  position. 
The  visceral  tonus  is  invariably  of  the  highest  degree,  stomach, 
small  intestine,  and  colon  being  equally  striking  as  to  their  hyper- 
tonicity.  The  stomach  is  of  Schlesinger 's  hypertonic  form  or 
Holzknecht's  bull-horn  type.  The  pylorus  is  the  lowest  or  nearly 
the  lowest  part  of  the  stomach.  The  small  intestine  is  high  in  the 
abdomen  and  equally  characteristic  as  to  its  hypertonicity  which 
is  shown  especially  by  the  narrow  worm-like  outline  of  the  loops 
of  ileum  in  contradistinction  to  the  broad  more  or  less  regular 
shadows  of  the  ileum  in  subjects  of  poor  visceral  tonus.  The 
colon  is  very  high  in  position,  the  cecum  being  well  above  the 
iliac  basin,  even  with  the  patient  standing.  The  transverse  colon 
is  horizontal.  The  descending  colon  is  long  owing  to  the  high 
position  of  the  intestines  and  more  nearly  straight  in  its  entirety 
than  in  other  types.  Visceral  hypertonicity  characteristic  of 
hypersthenics  is  possibly  most  strikingly  shown  in  the  multiplic- 
ity of  the  colonic  haustrge  and  their  sharp  and  deep  demarcation. 
Alimentary  motility  is  faster  in  the  hypersthenic  than  in  any 
other  type.  The  contrast  meal  pours  from  the  stomach  immedi- 
ately on  ingestion.  Small  intestinal  and  colonic  motilities  are 
commensurably  rapid,  the  contrast  substance  being  frequently 
passed  per  rectum  within  twelve  hours.  Such  subjects  charac- 
teristically defecate  two  or  more  times  in  the  twenty-four  hours. 
The  pure  type  is  rare.  I  have  seen  less  than  a  dozen  in  x-ray 
type  studies  of  some  two  thousand  subjects — I  have  never  seen 
a  woman  of  pure  hypersthenic  habitus  though  a  few  have  been 
observed  that  approached  it.  Such  women  are  far  more  mascu- 
line in  their  general  bodily  physical  characteristics  than  are 
many  men. 

In  order  to  best  appreciate  variations  in  type  both  of  physique 
and  topography,  it  will  be  best  to  consider  next  that  habitus 
which  is  the  antithesis  of  the  hypersthenic,  the  second  dominant 
type  the  asthenic  (Fig.  67).  The  asthenic  type  occurs  at  the 
other  end  of  the  scale  in  a  series  of  types  representing  grada- 
tions between  extremes.  Stiller  immortalized  himself  by  his  con- 
ception of  this  type,  his  "Asthenia  universalis  congenita," 
though  his  work  has  had  to  await  the  x-ray  for  its  fullest  appre- 


ASTHENIC   HABITUS  341 

eiation.  Persons  of  this  type  are  most  commonly  women  of  frail 
slender  build  having  a  delicate  bony  structure,  feeble  muscula- 
ture, and  but  little  body  fat.  The  thorax  is  long  and  gracile,  the 
intercostal  angle  is  narrow  and  the  ensiform  absent  or  rudimen- 
tary. The  pelvis  is  flat  and  capacious.  The  most  striking  and 
essential  characteristic  of  the  asthenic  is  the  marked  dispropor- 
tion between  the  great  capacity  of  the  pelvis  and  the  limited 
capacity  of  the  upper  abdomen  and  lower  thorax,  this  of  neces- 
sity determining  a  pelvic  digestive  plant  and  a  thoracic  topogra- 
phy corresponding  thereto  in  its  disproportionately  long  longi- 
tudinal dimensions  as  compared  to  its  short  lateral  distances. 
How  great  this  disproportion  between  the  pelvic  capacity  and 
that  of  the  upper  abdomen  may  be  appreciated  by  considering 
other  factors.  The  pelvis  of  a  woman  of  pure  asthenic  type  is 
often  far  broader  and  more  capacious  than  that  of  a  woman  ap- 
proaching the  hypersthenic  type,  this  though  the  lower  thorax 
of  the  latter  is  twice  the  capacity  of  that  of  the  former  and  the 
body  weight  frequently  twice  as  much.  The  form  of  the  lung 
fields  is  markedly  influenced  by  the  asthenic  habitus;  they  are 
relatively  broad  in  their  upper  zones  and  narrow  in  their  lower, 
in  contradistinction  to  those  of  the  hypersthenic.  The  diaphragm 
slopes  sharply  downward  to  each  side  though  very  frequently 
this  is  less  marked  owing  to  general  static  changes  resulting  in  a 
degree  of  figure  collapse.  The  lung  apices  are  large  and  extend 
well  above  the  clavicles.  The  lung  fields  appear  large  for  the 
individual  probably  because  anteroposteriorly  shallow  and  on 
account  of  the  meager  fat  and  muscular  clothing  of  the  body 
frame.  The  heart  is  of  that  peculiar  form  described  as  drop 
heart  being  narrow  and  pendant.  It  is  median  in  position  its 
long  axis  being  in  that  of  the  longitudinal  axis  of  the  body.  In 
general  its  position  is  well  above  the  diaphragm.  The  aortic 
outline  is  long  narrow  and  above  is  deflected  to  the  left  as  a  club- 
shaped  terminal.  In  keeping  with  the  relatively  great  capacity 
of  the  lower  abdomen,  the  digestive  plant  is  low  in  position.  The 
stomach  is  largely  pelvic  as  are  the  ileum  and  colon.  The  form 
of  the  various  portions  of  the  digestive  tube  is  characteristic  and 
some  portions  bear  hardly  a  resemblance  to  the  similar  structures 
of  the  hypersthenic.  The  stomach  appears  as  a  pendant  sac  and 
is  of  that  peculiar  form  designated  by  Schlesinger  as  atonio. 


342 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


The  ileum  is  capacious  and  the  colon  is  characterized  by  its  large 
cecum  and  the  coarseness  of  its  haustration.  Equally  striking 
and  constant  with  the  differences  in  position  and  form  of  the 
viscera  in  the  asthenic  and  hypersthenic  is  the  difference  in  the 


Fig.  66. — The  hypersthenic  habitus,  a  dominant  type.  Essential  characteristics  are  mas- 
sive figure,  short  deep  capacious  thorax,  very  obtuse  intercostal  angle,  with  wide  well- 
developed  ensiform.  Lung  fields  very  wide  at  base  and  narrowing  rapidly  to  their  apices. 
A  heart  whose  longitudinal  axis  is  almost  horizontal.  A  long  abdomen  relatively  more 
capacious  in  its  upper  zones  and  housing  a  digestive  plant  of  very  high  position.  The 
highest  degree  of  visceral  tonus  and  the  most  rapid  alimentary  motility  of  any  type  are 
other  characteristics.     (Mills.) 


VISCERAL  ATONY   CHARACTERISTIC   OF   THE  ASTHENIC 


343 


degree  of  alimentary  tonus.  The  essential  tonal  attribute  of  the 
asthenic  is  atony.  The  parts  of  the  alimentary  tube  in  the 
asthenic  are  never  endowed  with  sufficient  muscular  tonus  to 
support  their  contents.  The  contractility  of  the  sphincters  is 
also  poor  as  shown  by  the  ease  with  which  the  pylorus  may  be 


Fig.  67. — The  asthenic  habitus,  a  dominant  type.  Essential  characteristics  are  frail, 
slender  figure,  a  great  disproportion  between  the  capacious  pelvis  and  wide  hips  and  narrow 
upper  abdomen  and  lower  thorax,  a  very  narrow  intercostal  angle  with  no  or  only  a  rudi- 
mentary ensiform  is  constant.  The  lung  fields  are  relatively  narrow  in  their  lower  zones 
and  wide  in  their  upper.  The  diaphragm  slopes  sharply  downward  to  both  sides  from  the 
median  line.  The  heart  is  central  in  position,  its  long  axis  being  approximately  in  that 
of  the  body  median  line.  It  is  of  characteristic  pendant  form  and  its  shadow  is  but  little 
covered  by  the  silhouette  of  the  diaphragm.  Stomach  and  intestines  are  very  low  in  posi- 
tion, conforming  to  the  regional  capacities  of  the  abdomen.  The  form  of  the  stomach 
and  colon  is  very  characteristic.  The  degree  of  alimentary  tonus  is  the  poorest  and  gastro- 
intestinal motility  the  slowest  of  any  type.     (Mills.) 


344  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

overcome  by  manual  manipulation  as  shown  by  the  fluoroscope 
and  the  poor  tonus  of  the  rectal  sphincter.  Alimentary  motility 
is  slower  in  the  asthenic  than  in  any  other  type.  The  stomach 
not  infrequently  does  not  completely  empty  within  six  hours 
after  a  standard  bismuth  meal,  this  without  organic  cause  for 
such.  The  motility  of  small  and  large  intestine  is  commensurably 
slow.  The  comparison  of  asthenic  and  hypersthenic  might  be 
continued  to  show  an  antithesis  in  almost  every  physical  physio- 
logical and  psychical  attribute. 

In  the  assumption  of  such  an  idea  as  of  a  multiplicity  of  nor- 
mal anatomical  and  physiological  types  one  may  ask  on  what 
basis  such  a  conception  rests,  a  conception  opposing  the  generally 
accepted  idea  of  a  single  normal  type  with  variations  from  such, 
for  instance,  low  position  of  the  viscera  representing  acquired 
pathological  conditions,  an  idea  that  has  been  accepted  since  the 
days  of  Glenard  and  emphasized  by  the  writings  of  Ewald,  Wol- 
kow  and  even  Stiller,  who  while  accurately  describing  the  type 
designated  by  him  the  asthenic,  held  that  such  type  is  peculiar 
in  that  it  predisposed  to  visceroptosis. 

Of  any  single  species  of  organism  man  shows  the  widest  varia- 
ion  in  his  visible  characteristics.  This  owing  to  his  wide  geo- 
graphic distribution,  to  great  difference  in  his  manner  of  living 
and  most  to  the  advent  of  reason  as  a  modifier  of  those  natural 
evolutionary  processes  that  have  resulted  in  the  creation  of  fixed 
species  among  the  lower  animals  who  vary  but  little  from  their 
species  type  and  within  limited  bounds.  There  is  frequently 
greater  physical  variation  among  the  children  of  the  same  parents 
than  in  different  species  among  the  lower  animals.  One  has  but  to 
suggest  the  difference  in  faces  and  hands  or  of  the  ratio  of  body 
height  to  weight.  Man  is  not  a  species  of  fixed  physical  char- 
acteristics varying  within  narrow  limits.  It  does  not  seem  rea- 
sonable that  the  viscera  housed  in  bodies  varying  so  widely  must 
be  of  one  type  as  to  form  and  arrangement  to  be  considered  nor- 
mal. Again,  certain  bodily  structures  whose  form  could  not  pos- 
sibly be  modified  by  any  acquired  characteristic  such  as  viscerop- 
tosis, are  as  characteristic  of  certain  types  associated  with  low  posi- 
tion of  stomach  and  intestine  as  are  other  bodily  peculiarities  that 
might  be  interpreted  as  the  result  of  such  ptosis.  For  instance 
the  form  and  relative  capacity  of  the  pelvis  in  the  asthenic  type 


JUSTIFICATION   OF  A   TYPE  ANATOMY  AND  PHYSIOLOGY         345 

could  not  possibly  be  changed  by  any  degree  of  splanchnoptosis, 
yet  the  proportions  and  structure  of  the  pelvis  are  absolutely 
typical  of  such  habitus.  It  is  always  possible  under  usual  con- 
ditions to  anticipate  the  peculiar  form,  and  low  position  of  the 
stomach  of  an  asthenic  from  a  radiograph  of  his  pelvis  alone. 

Further  it  is  difficult  to  reconcile  ourselves  to  the  idea  of  a  con- 
dition being  essentially  pathologic  that  exists  in  so  great  a  pro- 
portion of  healthy  subjects.  It  is  true  that  asthenics  are  of  an 
inferior  type;  that  they  are  not  strong  physically;  that  they  are 
nervously  unstable,  fatigable  and  prone  to  digestive  disorders. 
On  the  other  hand,  every  walk  of  life  is  crowded  with  those  of 
this  type  who  never  had  a  digestive  disturbance  and  who  fre- 
quently show  a  surprising  endurance  and  capacity  for  work.  It 
is  not  meant  to  imply  that  ptosis  of  the  viscera  does  not  occur, 
but  the  position  is  taken  that  before  such  is  assumed  there  must 
be  a  departure  from  that  abdominal  topography  to  which  the  in- 
dividual is  entitled  on  the  basis  of  his  general  structural  type. 

On  the  same  basis  we  may  assume  with  equal  propriety  and 
utilize  diagnostically  an  elevation  of  the  viscera  when  the  posi- 
tion of  such  is  higher  than  the  type  standard  for  that  particular 
person.  A  scirrhus  carcinoma  of  the  stomach  in  an  asthenic  re- 
sults in  a  stomach  of  higher  position  than  we  should  consider 
normal  on  the  basis  of  physique.  On  the  other  hand  if  a  benign 
pyloric  stenosis  with  resulting  atony  occurs  in  a  hypersthenic 
subject  the  stomach  may  be  low  for  that  particular  type  of 
individual  though  still  well  above  the  umbilicus. 

One  of  the  strongest  arguments  in  favor  of  a  type  anat- 
omy is  that  certain  persons,  essentially  asthenic  yet  hav- 
ing none  of  those  physical  peculiarities  supposed  to  cause 
ptosis  still  have  abdominal  viscera  of  low  position  and  charac- 
teristic asthenic  form.  A  number  of  studies  of  women  have  been 
made  who  present  the  essential  structural  characteristics  of  the 
asthenic  yet  who  weigh  as  much  as  one  hundred  and  eighty 
pounds,  are  fairly  muscular,  and  of  good  static  poise.  This  vis- 
ceral topography  is  purely  asthenic,  the  stomach  and  intestines 
being  low  in  position,  of  a  relatively  poor  degree  of  tonus,  and  of 
that  characteristic  form  typical  of  the  ''congenital  enteroptotic. " 

It  is  not  contended  that  the  relationship  between  bodily  habitus 
and  visceral  form,  position,  tonus  and  motility  is  always  constant. 


346 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


Not  infrequent  variations  occur  but  it  is  held  that  in  extremes  of 
type  this  relationship  is  positive  and  in  intermediate  types  it 
holds  to  a  degree  that  makes  a  type  anatomy  and  physiology  the 
most  hopeful  possibility  of  escape  from  the  chaos  that  has  re- 
sulted from  our  present  one  type  standard. 


Fig.  68. — The  sthenic  habitus,  a  major  type.  The  characteristics  of  this  type  are  very 
similar  to  those  of  the  hypersthenic,  but  differ  in  that  they  are  all  less  marked  than  in 
that  type  (Fig.  66).  Thus  the  general  physique,  while  as  a  rule  heavy  and  powerful,  lacks 
the  peculiar  massiveness  of  the  hypersthenic.  In  the  sthenic  the  thorax  is  short  and  wide, 
the  intercostal  angle  of  about  ninety  degrees.  The  lung  fields  are  relatively  wide  in  their 
lower  zones.  The  longitudinal  diameter  of  the  heart  is  somewhat  transverse.  The  abdomen 
is  rather  long  the  alimentary  viscera  high  in  position.  Gastrointestinal  motility  is  fast  and 
stomach  and  intestinal  tonus  of  high  degree.      (Mills.) 


INTERMEDIATE   TYPES 


347 


The  principle  of  type  topography  has  been  illustrated  by  the 
description  of  the  two  most  widely  varying  types,  the  hypersthenic 
and  asthenic.  Between  these  two  occur  an  infinite  variety  of 
physical  forms  and  visceral  plans.    Among  these  are  two  types 


Fig.  69. — The  hyposthenic  habitus,  a  major  type.  Essentially  an  intermediate  habitus, 
numerically  common.  It  is  the  most  difficult  type  to  classify,  as  all  _  characteristics 
approach  a  mean.  In  general,  the  structural  characteristics  are  sthenic,  while  the  visceral 
arrangement  is  more  that  of  the  asthenic.  Hyposthenics  also  most  frequently  resemble 
the  asthenic  in  their  lack  of  robustness.  The  thorax  is  moderately  long  the  intercostal 
angle  narrow,  usually  about  forty  degrees,  with  the  ensiform  rudimentary  or  lacking.  The 
lung  fields  are  intermediate  in  their  general  proportion  between  those  of  the  sthenic  and 
asthenic  types.  The  heart  resembles  that  of  the  asthenic.  Frequently  it  is  of  quite  pen- 
dant form.  The  stomach  is  moderately  low  in  position  and  the  intestines  occupy  a  relative 
position.  Visceral  tonus  is  rather  poor  on  the  whole  though  of  higher  degree  than  in 
the  asthenic.    Alimentary  motility  is  of  average  rate.     (Mills.) 


348 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


that  seem  constant  enough  to  afford  a  basis  of  type  classifica- 
tion. The  first  is  the  sthenic  (Fig.  68)  and  the  second  the  hypo- 
sthenic  (Fig.  69).  As  the  names  imply,  they  are  types  in  which 
sthenic  characteristics  are  dominant  though  differing  in  their 
degree.  Our  classification  may  be  now  stated  as  a  division  into 
four   major   types    arranged   in   gradations:    hypersthenic    (Fig. 


Fig.  70. — The  hypersthenic  to  sthenic  habitus,  a  sub-type.  In  this  habitus  physical  and 
visceral  characteristics  are  essentially  hypersthenic  (Fig.  66)  though  not  as  markedly  so  as 
in  that  type  but  tend  somewhat  to  the  next  lower  form,  the  sthenic  (.Fig.  68).  Thus  the 
thorax  has  not  quite  the  depth  of  the  hypersthenic  and  the  intercostal  angle  is  less  obtuse. 
The  stomach  is  not  quite  so  extreme  in  form  and  position;  other  characteristics  are  rela- 
tively modified.     (Mills.) 


NECESSITY   OF  SUB-TYPES 


349 


66),  sthenic  (Fig.  68),  hyposthenic  (Fig.  69),  and  asthenic  (Fig. 
67).  Variation  in  the  physique  and  visceral  topography  of  dif- 
ferent subjects  is  so  great  that  this  classification  is  not  sufficient- 
ly elastic  to  lend  itself  to  practical  use.  We  must  have  finer 
subdivision  of  these  types.  To  meet  this  requirement  every  sub- 
ject is  primarily  classified  as  of  that  one  of  the  above  four  divi- 
sions that  his  essential  bodily  peculiarities  assign  him.  Should 
his  general  habitus  be  purely  that  of  one  of  these  types,  no 


Fig.  71. — Sthenic  to  hypersthenic  habitus,  a  sub-type.  Here  the  essential  characteristics 
are  those  of  the  sthenic  (Fig.  68)  but  somewhat  more  suggestive  of  the  hypersthenic 
(Fig.  66)  than  is  the  case  in  the  pure  sthenic.  The  thorax  is  a  little  shorter,  the  inter- 
costal angle  somewhat  wider  and  the  whole  figure  more  massive  than  in  the  sthenic. 
Visceral  form,  position,  and  other  peculiarities  are  similarly  modified.      (Mills.) 


350 


PHYSICAL  EXAMINATION  OF  ORGANS  OP  THORAX 


further  classification  is  necessary.  If  however  he  be  essentially 
of  one  of  them  yet  present  other  characteristics  suggesting  the 
group  above  or  below  him,  he  is  classified  as  primarily  of  that 
one  of  the  four  major  types  that  he  most  resembles  yet  tending 
to  another.  We  thus  have  six  sub-types  (Figs.  70,  71,  72,  73,  74, 
and  75).    An  individual  may  be  essentially  sthenic  yet  tend  to 


Fig.  72.— Sthenic  to  hyposthenic  habitus,  a  sub-type.  While  the  general  structure  is 
here  sthenic  (Fig.  68)  there  is  a  tendency  to  the  hyposthenic  (Fig.  69).  This  is  shown  by 
a  less  marked  robustness,  a  longer  thorax  and  shorter  abdomen  than  in  the  pure  sthenic. 
The  visceral  topography  and  other  peculiarities  are  proportionately  intermediate.     (Mills.) 


CLASSIFICATION   OF  SUB-TYPES 


351 


the  hypersthenic  in  which  instance  he  is  classified  as  "sthenic  to 
hypersthenic"  (Fig.  71),  or  he  may  be  dominantly  a  sthenic  yet 
tend  down  the  scale  to  the  hyposthenic.  He  would  then  be  classi- 
fied as  sthenic  to  hyposthenic  (Fig.  72).  This  classification  is 
partly  the  result  of  an  effort  to  build,  as  is  fitting,  on  certain 


Fig.  73. — The  hyposthenic  to  sthenic  habitus,  a  sub-type.  In  this  sub-form  the  char- 
acteristics of  the  hyposthenic  (Fig.  69)  are  dominant  though  the  figure  and  alimentary 
peculiarities  are  somewhat  more  sthenic  (Fig.  68)  than  in  the  pure  hyposthenic.  Thus  the 
intercostal  angle  is  wider,  the  position  of  the  stomach  higher  and  its  tonus  more  marked. 
(Mills.) 


352 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


work  that  lias  already  been  recognized,  namely  Stiller 's  descrip- 
tion of  his  asthenic  and  sthenic  types  and  Schlesinger 's  classifi- 
cation of  stomach  forms  into  hypertonic,  orthotonic,  hypotonic, 
and  atonic.  This  latter  classification  lends  itself  as  a  parallel 
to  the  above  classification.     Schlesinger 's  hypertonic  stomach  is 


Fig.  74, — The  hypersthenic  to  asthenic  habitus,  a  sub-type.  While  essentially  hypersthenic 
(Fig.  69)  there  is  considerable  suggestion  of  the  asthenic  (Fig.  67)  in  this  type.  This  is 
shown  in  the  long  thorax  with  somewhat  narrow  intercostal  angle  but  especially  by  the 
relatively  wide  pelvis,  which,  with  the  vertical  heart  and  moderately  low  position  of  the 
somewhat  atonic  abdominal  viscera,   distinctly  suggest  the  asthenic.      (Mills.) 


RELATION    OF   STOMACH   TYPES    TO    HABITUS 


353 


essentially  the  stomach  of  the  hypersthenic  (Fig.  66)  his  atonic 
stomach  that  of  the  asthenic  (Fig.  67).  The  orthotonic  stomach 
corresponds  to  the  sthenic  (Fig.  68),  though  less  exactly  than 
do  the  other  stomach  forms  to  their  parallel  habits.  The  hypo- 
tonic stomach  is  the  stomach  of  the  hyposthenic  (Fig.  69).  The 
classification  proposed  may  be  used  as  a  division  of  all  subjects  into 
two  types  in  which  sthenic  or  asthenic  characteristics  are  dominant, 
as  a  division  into  four  major  types,  or  may  include  a  classification 


Fig.  75. — The  asthenic  to  hyposthenic  habitus,  a  sub-type.  Essentially  characteristic  are 
those  of  the  asthenic  (Fig.  67)  though  there  is  a  suggestion  of  the  hyposthenic  (Fig.  69) 
in  the  only  moderately  wide  pelvis  and  the  lack  of  that  extremely  low  position  of  the 
stomach  found  in  the  pure  asthenic.     (Mills.) 


354 


PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 


of  sub-types.    Our  classification  may  be  illustrated  by  the  following 
schema : 


Hypersthenic 
tending  to 
sthenic 


Sthenic  Sthenic 

tending  to     tending  to 
hypersthenic  hyposthenic 


Hyposthenic 
tending  to 
sthenic 


Groups    in    which    sthenic    characteristics    are 
dominant. 


Dominant  Types 

Hypersthenic 

Asthenic 

Major  Types 

Hypersthenic 

Sthenic 

Hyposthenic 

Asthenic 

Sub-Types 

Hyposthenic 
tending  to 
asthenic 


Asthenic 
tending  to 
hyposthenic 


Groups  in  which  asthenic 
characteristics  are  dom- 
inant. 


The  sthenic  type  (Fig.  68)  may  be  best  described  as  one  in 
which  the  peculiarities  of  that  type  heretofore  described  as 
hypersthenic  are  present  but  in  a  less  marked  degree — "Sthenic" 
subjects  are  heavy  powerful  individuals  of  generous  body  archi- 
tecture, deep  chests,  wide  intercostal  angle,  high  digestive  plant, 
and  having  more  than  an  average  degree  of  visceral  tonus.  They 
are  a  common  type.  Most  of  the  heavy  robust  persons  of  one's 
acquaintance  are  sthenics.  The  lung  fields  of  the  sthenic  re- 
semble those  of  the  hypersthenic  quite  closely  in  that  they  are 
also  relatively  wider  at  the  base  and  narrower  in  their  upper 
zones.  Their  longitudinal  dimensions  are  short,  less  so  than  in 
the  hypersthenic  but  more  so  than  in  other  types.  The  di- 
aphragm approaches  the  horizontal.  The  heart  is  less  transverse 
than  in  hypersthenics  but  more  so  than  in  lower  types.  It  does 
not  appear  as  submerged  in  the  diaphragmatic  contour  as  in 
the  pure  hypersthenic.  The  intercostal  angle  is  obtuse,  usually 
about  ninety  degrees.  The  ensiform  is  well  developed.  The  ali- 
mentary tract  is  high  in  position.  The  stomach  is  entirely  or 
nearly  entirely  above  the  umbilicus,   or  perhaps  better,   above 


HYPOSTHENIC   HABITUS  355 

the  level  of  the  anterior  iliac  spines.  The  transverse  colon  is, 
as  a  rule,  above  the  same  landmarks  (standing  position).  Other 
parts  of  the  intestines  occupy  a  proportionately  high  position. 
Visceral  tonicity  is  of  a  high  degree.    Alimentary  motility  is  fast. 

The  remaining  type  is  the  hyposthenic  (Fig.  69).  Subjects  of 
this  type  are  the  most  difficult  of  classification  of  any  type  be- 
cause while  the  general  bodily  characteristics  are  more  sthenic 
than  asthenic,  the  chest  and  visceral  arrangement  in  a  large  pro- 
portion of  cases  resembles  that  of  the  asthenic  in  the  form  of 
the  lung  field,  general  direction  of  heart  axis  and  low  position 
of  the  abdominal  viscera.  However,  while  thoracic  and  abdom- 
inal topographies  resemble  those  of  the  asthenic,  the  visceral 
forms  are  not  those  peculiar  to  that  type  (Figs.  69  and  67). 
Those  of  hyposthenic  type  are  generally  somewhat  frail  in  phy- 
sique, in  fact  many  women  of  this  type  would  at  first  sight  seem 
to  be  of  asthenic  habitus.  They  lack,  however,  certain  pecul- 
iarities of  such  type  especially  the  disproportionately  wide  and 
capacious  pelvis.  Each  lung  field  is  more  vertical  and  wide  in 
its  upper  zone  than  in  those  types  in  which  sthenic  charac- 
teristics are  marked.  The  diaphragm  is  quite  sloping.  The 
heart  approaches  a  vertical  position,  often  has  quite  the  pecul- 
iarities of  the  hanging  heart.  The  intercostal  angle  is  narrow; 
usually  less  than  ninety  degrees;  the  ensiform  rudimentary  or 
lacking.  The  alimentary  viscera  are  rather  low  in  position,  a 
considerable  part  of  the  stomach  being  below  the  umbilicus.  The 
intestines  occupy  a  relative  position;  alimentary  tonus  is  of  but 
fair  degree  and  motility  of  average  or  less  than  average  rate. 

The  various  types  are  better  appreciated  by  the  accompanying 
diagrams,  each  of  which  is  the  accurate  scale  record  of  an  in- 
dividual, than  by  description.  It  is  better  at  first  to  accustom 
oneself  to  classifying  all  subjects  into  one  of  the  four  major 
types  without  attempting  to  use  the  sub-types. 

The  recognition  of  the  different  types  is  a  matter  of  experience 
and  practice  and  is  often  difficult.  In  some  cases  a  subject  is 
almost  impossible  of  classification  owing  to  a  complexity  of  char- 
acteristics; the  thorax  may  be  of  one  type,  the  abdomen  and 
visceral  topography  of  another;  such  are,  however,  very  much 


356  PHYSICAL  EXAMINATION  OF  ORGANS  OF  THORAX 

in  the  minority.  A  most  confusing  type  is  one  in  which  the  gen- 
eral habitus  is  one  of  the  intermediate  types,  yet  the  degree  of 
visceral  tonus  owing  probably  to  an  unusual  balance  in  the  au- 
tonomic nervous  system  is  extreme  or  deficient  giving  the  differ- 
ent parts  of  the  alimentary  tract  the  position  and  form  of  a 
higher  or  lower  type. 

To  summarize,  physical  and  visceral  types  are  best  recog- 
nized by  an  appreciation  of  their  extremes :  the  hypersthenic  and 
asthenic,  all  other  types  represent  intergradations  between  these 
two.  Secondly,  by  the  recognition  of  two  main  intermediate 
types,  the  sthenic  and  hyposthenic,  and  thirdly,  by  variations 
of  these  four  types  in  the  form  of  certain  sub  types  primarily 
one  of  the  four  main  types  but  tending  to  the  next  higher  or 
lower  type  in  the  scale. 


CHAPTER  XIV. 

THE    DIAGNOSIS    OF    EARLY    PULMONARY    TUBERCU- 
LOSIS:   HISTORY  AND  CLINICAL  SYMPTOMS. 

Meaning"  of  Early  Diagnosis. — There  are  many  misconcep- 
tions regarding  the  early  diagnosis  of  tuberculosis.  These  have 
been  largely  unavoidable  up  to  the  present  time,  because  our  pic- 
ture of  this  early  condition  has  been  based  on  a  faulty  concep- 
tion of  the  disease. 

What  we  mean  by  early  diagnosis  of  tuberculosis  may  noFbe, 
in  fact  rarely  is,  a  diagnosis  made  soon  after  the  bacilli  have  en- 
tered the  body.  It  may  be  months,  often  years,  after  the  original 
infection  has  occurred  that  the  patient  observes  the  first  symp- 
toms and  presents  himself  for  examination.  What  we  have  been 
hitherto  considering  as  early  tuberculosis,  considered  from  the 
standpoint  of  the  time  when  infection  occurs,  is  really  late  tuber- 
culosis in  most  instances.  It  is  a  condition  in  the  life  history  of 
the  disease  which  represents  not  a  primary  invasion  but  an  ex- 
tension to  new  tissue ;  and,  often,  a  renewed  activity  in  one  of 
these  extensions. 

Tuberculosis  is  primarily  a  disease  of  the  lymphatic  system, 
the  time  of  the  infection  being  childhood  (see  page  84).  No 
matter  where  or  how  bacilli  gain  entrance  to  the  body  they  pass 
into  the  lymphatic  channels  and  are  screened  out  by  the  lym- 
phatic glands,  those  of  the  mediastinum  most  frequently.  This 
constitutes  the  truly  incipient  stage  of  tuberculosis.  These  early 
mediastinal  infections  are  found,  as  a  rule,  postmortem;  but 
they  may  be  inferred  by  a  positive  tuberculin  test  when  infection 
of  other  organs  has  been  eliminated.  Infection  of  the  glands 
is  rarely  physically  demonstrable  until  the  disease  has  existed 
for  some  time  and  the  bacilli,  finding  themselves  suited  to  the 
new  soil,  have  already  multiplied  and  produced  a  somewhat  ad- 
vanced pathological  process. 

There  is  a  greater  similarity  between  tuberculosis  and  syphilis 


358  DIAGNOSIS   OP  EARLY  PULMONARY   TUBERCULOSIS 

than  is  generally  believed.  We  are  told  how  syphilis  may  sim- 
ulate so  many  other  diseases  in  its  clinical  picture.  Tubercu- 
losis does  the  same,  as  I  shall  describe  when  discussing  clinical 
symptoms.  Syphilis  has  been  divided  into  the  primary,  sec- 
ondary and  tertiary  stage.  Tuberculosis  may  also  be  so  divided, 
lianke,  of  Munich,  likens  the  early  lymphatic  form  of  tubercu- 
losis, the  invasion,  to  the  primary  stage  of  syphilis ;  the  extension 
to  new  tissue, — it  may  be  to  distant  organs  such  as  the  lungs, 
kidneys,  bowels,  and  meninges, — to  the  second  stage  of  syphilis; 
and  the  advanced  lesions  with  their  destructive  processes  and 
general  systemic  disturbances  to  the  gummatous  or  tertiary  stage 
of  that  disease.  This  comparison  is  of  more  than  usual  interest 
to  clinicians  and  at  once  impresses  forcibly  upon  the  medical 
profession  facts  which  are  of  paramount  importance  to  a  rational 
understanding  and  the  early  detection  of  tuberculosis,  viz. ;  that 
it  is  a  disease  of  long  duration,  presenting  a  varied  picture  in  its 
pathological  aspects  at  different  stages,  and  presenting  a  symp- 
tom-complex, requiring  careful  study;  and,  further,  that  the  so- 
called  early  diagnoses  are  diagnoses  of  conditions  which  present 
an  advancing  process. 

The  problem  of  the  diagnosis  of  early  tuberculosis  as  recog- 
nized today,  then,  is  that  of  detecting  the  disease  in  what  might 
be  termed  the  second  stage  of  its  development,  the  stage  of  in- 
creased activity  as  applied  to  the  lymphatic  glands  or  of  exten- 
sion to  new  tissue,  or  of  any  successive  increased  activity  or  ex- 
tension from  a  previously  quiescent  focus. 

Clinical  Tuberculosis. — The  writer  has  been  in  the  habit  of 
speaking  of  the  condition  just  mentioned  as  clinical  tuberculosis 
in  order  to  differentiate  it  from  the  primary  infection  (the  truly 
incipient  tuberculosis)  and  primary  metastasis  in  the  lung, 
which  so  often  becomes  quiescent ;  both  of  which  are  often  spoken 
of  lightly  as  anatomical  tuberculosis.  It  is  well,  however,  to 
call  attention  to  the  fact  that  our  best  opinion  today  supports 
the  idea  that  much  of  the  "clinical  tuberculosis"  is  an  exten- 
sion from  the  so-called  anatomical  tuberculosis,  showing  that  the 
latter  condition  deserves  far  more  consideration  at  the  hands 
of  clinicians  than  it  now  receives. 


RELATION   OF    CLINICAL   DIAGNOSIS    TO   INFECTION  359 

This  conception  puts  new  meaning  into  early  diagnosis,  and 
impresses  upon  clinicians  the  seriousness  of  the  advanced  and 
advancing  condition  which  we  have  been  wont  to  consider  as  an 
early  manifestation.  While  experience  shows  that  many  of  those 
who  suffer  from  clinical  tuberculosis  will  get  well,  even  by  the 
adoption  of  simple  measures,  the  fact  that  one-tenth  of  the  hu- 
man race  still  dies  of  this  disease  is  sufficient  to  demand  that 
clinical  tuberculosis  be  recognized  and  treated  seriously. 

Relationship  of  Clinical  Diagnosis  to  Infection. — This  shows 
clearly  that  if  we  would  understand  early  diagnosis,  it  is  neces- 
sary to  study  infection;  to  know  when  it  takes  place  and  what 
occurs  when  it  has  taken  place.  It  is  not  sufficient  to  know  that 
there  is  a  pathological  thickening  of  the  tissues,  accompanied  by 
certain  signs  and  symptoms ;  it  is  just  as  important  to  know  that 
the  cells  of  the  body  are  changed  and  sensitized  toward  further 
attacks  of  the  tubercle  bacillus.  If  a  subsequent  inoculation  of 
bacilli  takes  place,  the  phenomena  which  occur  as  a  result  of  the 
struggle  between  the  invading  bacilli  and  the  invaded  organism 
are  not  the  same  as  those  in  the  primary  infection.  If  the  num- 
bers of  bacilli  in  the  subsequent  inoculation  are  sufficiently  large, 
a  recognizable  train  of  symptoms  occurs  which  is  due  to  the 
struggle  between  the  invading  bacilli  and  the  cells  of  the  body 
which  are  now  endowed  with  specific  defensive  powers  and  the 
antibodies  which  the  cells  produce  for  the  specific  purpose  of 
warding  off  the  invasion.  If  this  subsequent  inoculation  is  made 
experimentally  by  injecting  bacilli  into  the  soft  tissues  of  an 
animal  already  tuberculous  (Koch's  experiment,  page  82)  a 
local  ulcer  forms,  the  bacilli  are  cast  off,  and  the  regional  lymph 
glands  are  not  even  infected.  If  the  superinfection  is  made 
through  the  blood  or  lymph  stream,  the  bacilli  settle  somewhere 
in  the  tissues;  and  the  reaction  (specific  cellular  reaction)  be- 
tween the  tissue  cells  and  the  bacilli  again  shows  differently 
from  what  it  does  if  it  is  a  primary  infection,  although  the 
difference  may  not  be  so  evident  as  it  is  when  the  bacilli  are  in- 
jected into  the  tissues.  Many  of  the  bacilli  are  destroyed;  and, 
while  if  the  numbers  are  large  enough,  infection  occurs,  yet  the 
process    assumes    a    chronic    form.     In    guinea    pigs    these    sub- 


360  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

sequent  infections  or  superinfections,  as  they  are  called  experi- 
mentally, show  evidence  of  cavity  formation  and  other  signs  of 
chronicity  while  the  primary  inoculation  develops  acute  dis- 
seminated tuberculosis.  The  nature  of  chronic  tuberculosis  with 
its  tendency  to  chronicity  and  cavity  formation  is  probably 
determined  by  the  specific  defensive  properties  with  which  the 
cells  are  endowed  (sensitized  condition)  and  must  be  thought  of 
as  analogous  to  the  phenomena  described  by  Koch  in  connection 
with  a  secondary  infection  of  a  previously  tuberculous  guinea  pig. 
All  abortive,  as  well  as  chronic  forms  of  tuberculosis,  whether  of 
the  fibroid,  or  fibro-ulcerative  form,  must  be  looked  upon  as 
having  this  specific  tissue  reaction  as  a  determining  factor. 

The  experimental  work  which  has  been  done  in  recent  years, 
when  interpreted  clinically,  goes  to  show  that  the  most  of  our 
instances  of  clinical  tuberculosis  are  reinfections  in  the  sense  that 
they  are  infections  which  have  taken  place  in  bodies  which  have 
been  previously  infected.  They  are  not  necessarily  infections  by 
new  bacilli  coming  from  some  source  outside  of  the  body  of  the 
individual,  but  most  probably  extensions  from  a  focus  within, 
which  may  have  been  the  result  of  a  recent  infection  or  one 
which  occurred  months  or  years  previously  (see  page  85).  The 
probability  of  this  is  established  by  pathological  and  clinical  evi- 
dence both  of  which  go  to  show  that  the  infection  of  the  human 
race  with  tubercle  bacilli  is  almost  universal  by  the  time  the 
fifteenth  year  has  been  reached  (see  pages  78  and  100). 

The  phenomena  which  present  themselves  at  the  time  of  the 
reinfection  vary  and  probably  depend  upon  the  degree  of  sen- 
sitization (specific  cellular  defense)  present,  the  numbers  and 
virulence  of  the  invading  bacilli,  the  suitability  of  the  soil  as  a 
culture  medium,  and  the  character  of  the  tissues  invaded.  Thus 
we  may  explain  the  varied  nature  of  the  symptoms  and  the  dif- 
ferences in  the  pathological  conditions  which  we  have  gradu- 
ally learned  to  recognize  as  accompanying  the  onset  of  clinical 
tuberculosis.  Thus  we  may  explain  the  fact  that  we  so  often  fail 
in  recognizing  the  early  manifestations  of  clinical  tuberculosis. 

Clinical  Diagnosis. — It  will  be  inferred  from  previous  discus- 
sion that  the  diagnosis  of  early  clinical  tuberculosis  takes  into 


CLINICAL  DIAGNOSIS  361 

consideration  two  distinct  conditions;  first,  the  diagnosis  of  the 
disease  when  it  first  invades  the  lung  tissues,  and,  second,  the 
diagnosis  of  the  disease  when  it  is  a  renewed  activity  in  an  old 
focus  of  infection  which  may  have  been  quiescent  for  a  longer  or 
shorter  period  of  time.  While  these  two  conditions  may  pre- 
sent similar  diagnostic  data;  on  the  other  hand,  they  may  pre- 
sent data,  particularly  that  which  is  obtained  on  physical  ex- 
amination, of  a  very  divergent  nature.  I  will  endeavor  to  make 
this  plain  as  my  discussion  proceeds  in  the  following  chapters. 

I  shall  take  up  each  of  the  recognized  methods  of  obtaining 
information  and  discuss  them  and  the  data  obtained  by  them 
and  endeavor  to  show  how  the  findings  vary  under  different 
conditions,  hoping  thus  to  make  clear  the  application  of  the 
measures  discussed. 

There  is  no  stereotyped  way  of  making  a  diagnosis  of  early 
pulmonary  tuberculosis.  The  diagnosis  is  not  always  based  on 
the  same  conditions.  It  is  not  based  on  data  derived  from  any 
particular  procedure,  but  it  is  an  opinion  formed  after  all  avail- 
able data  have  been  obtained  and  analyzed.  He  who  attempts 
to  find  the  same  symptoms  or  the  same  physical  signs  in  every 
instance  before  he  will  make  a  diagnosis  of  early  pulmonary  tu- 
berculosis fails  to  grasp  the  nature  of  the  process  which  he  is 
attempting  to  discover.  The  patient  suffering  from  early  clini- 
cal tuberculosis  usually  shows  only  a  few  of  the  many  symp- 
toms which  are  found  accompanying  this  condition,  and  these 
may  not  be  constant.  They  are  now  present  for  a  time  and  then 
may  disappear,  giving  the  patient  the  idea  that  they  are  gone, 
as  described  more  fully  in  Chapter  XXI.  Variability  is  neces- 
sarily characteristic  of  symptoms  and  signs  in  this  disease  because 
conditions  are  so  varied.  This  can  readily  be  appreciated  from  the 
discussion  which  has  preceded. 

The  diagnosis  of  early  clinical  tuberculosis  requires  time  for 
examination,  skill  in  obtaining  the  proper  data,  and  judgment 
in  weighing  the  data  when  obtained. 

Family  History. — The  family  history  was  formerly  of  first  im- 
portance, because  it  was  thought  that  tuberculosis  was  handed 
down  as  an  inheritance  from  one  generation  to  another;  but  now 


362 


DIAGNOSIS   OP  EARLY  PULMONARY   TUBERCULOSIS 


that  we  know  that  this  disease  is  an  infection  which  occurs  almost 
wholly  after  birth  we  attribute  a  different  meaning  to  it. 

The  history  of  open  tuberculosis  in  a  family,  if  it  has  offered 
opportunity  for  intimate  and  prolonged  association,  between  the 
one  affected  and  the  patient  now  under  examination,  is  very 
important,  and  especially  if  this  association  took  place  during  the 
early  years  of  the  patient's  life.  The  reason  why  so  much  im- 
portance is  attached  to  the  intimate  association  with  open  tu- 
berculosis in  early  childhood  is  because  the  closer  the  contact 
the  greater  the  danger  of  infection  with  large  numbers  of  bacilli ; 
and,  the  greater  the  numbers  of  bacilli  in  the  infecting  inocula- 
tion, the  greater  the  danger  of  the  disease  overcoming  the  nat- 
ural defensive  powers  and  assuming  serious  proportions.  While 
civilized  people  are  universally  exposed  to  tuberculosis,  those 
who  associate  intimately  with  it  are  exposed  to  the  greatest  ex- 
tent. This  is  illustrated  by  the  statistics  of  Cohn,  in  the  following 
table,  which  show  that  all  children  in  tuberculous  families  are 
infected  prior  to  the  fifteenth  year,  while  probably  10  or  15  per 
cent  of  those  in  non-tuberculous  families  escape.  Cohn,  cited  by 
Eomer1  gave  the  cutaneous  tuberculin  test  to  273  children  of  tu- 
berculous parents  and  found  as  follows: 

per  cent  gave  a  positive  reaction. 


Of  those  from    2-  3 

years, 

66 

4-  5 

>  y 

60 

6-  7 

> ) 

77% 

8-  9 

>  > 

77 

10-11 

>  ! 

80% 

12-13 

J  > 

89.9 

14 

}  ) 

100 

The  probability  is  that  the  children  of  tuberculous  families  also 
have  a  greater  immunity  than  those  of  the  non-tuberculous  fam- 
ilies, although  a  greater  per  cent  of  them  die  of  tuberculosis. 
The  assumption  on  which  we  base  the  opinion  of  greater  im- 
munity is  the  fact  that  if  these  children  in  tuberculous  families 
withstand  the  immediate  effects  of  the  relatively  larger  doses  of 
bacilli,  their  infections  so  often  present  abortive  and  chronic 
forms  of  tuberculosis.  On  the  other  hand,  the  greater  mortality 
usually  occurs  in  the  acute  forms  of  the  disease  such  as  meningitis 


trailer's  Beitrage  zur  Tuberkulose,  vol.  xxii,  1912. 


CLINICAL   HISTORY  363 

and  generalized  tuberculosis  which  occur  during  the  early  years 
of  life  before  specific  cellular  defense  has  been  obtained.  Von 
Euck  has  shown  that  specific  resistance  to  tubercle  bacilli  is 
transmitted  by  the  tuberculous  mother  to  her  child. 

What  are  we  to  say  of  the  danger  of  intimate  association  as  it 
occurs  in  the  family  of  the  tuberculous,  particularly  in  adult 
life  ?  Our  newer  studies  of  tuberculosis  show  that  there  is  a  high 
degree  of  immunity  developed  against  the  bacilli  by  the  time 
adult  life  is  reached.  And  we  are  permitted  to  infer  that  this 
is  sufficient  to  protect  the  individual  against  all  ordinary  in- 
oculations which  might  come.  It  is  also  probable  that  instances 
of  tuberculosis  as  we  find  them  in  adult  life  are  largely  due -to 
extensions  from  foci  within  the  body  rather  than  inoculations 
of  bacilli  from  without.  The  real  danger,  however,  comes  from 
bacilli  entering  the  tissues  in  sufficiently  large  numbers,  whether 
from  without  or  within,  to  break  down  the  protective  immu- 
nity and  cause  a  new  infective  process  to  be  set  up.  The  greatest 
danger  of  such  a  thing  happening  comes  when  the  individual  is 
exposed  most  intimately  to  great  numbers  of  bacilli,  such  as  in 
the  family  where  tuberculosis  is  present  in  the  advanced  destruc- 
tive stage.  Therefore,  when  the  history  of  association  with  open 
tuberculosis  in  the  family  is  positive,  it  is  the  examiner's  duty 
to  find  out  how  long  such  association  has  existed,  how  intimate 
it  was  and  at  what  period  of  life  it  occurred.  A  continuous  in- 
timate association  with  one  in  the  advanced  open  stage  of  the 
disease  may  be  of  great  importance  at  any  age,  but  it  is  particu- 
larly suggestive  during  the  early  years  of  the  patient's  life. 

CLINICAL  HISTORY. 

In  order  to  make  a  diagnosis  of  clinical  tuberculosis  early, 
it  is  necessary  for  the  examiner  to  disabuse  his  mind  of  the 
long  supposed  fact  that  a  tuberculous  patient  must  necessarily 
be  of  the  phthisical  habitus  with  flat  chest,  be  run  down,  and  be 
suffering  from  a  low  state  of  vitality.  Such  a  history  will  be 
obtained  in  many  cases,  but  not  in  all.  There  are  many  patients 
suffering  from  early  clinical  tuberculosis  who  are  of  robust  build, 
who  have  been  working  hard  and  doing  their  work  easily,  and 


364  DIAGNOSIS   OF  EARLY  PULMONARY  TUBERCULOSIS 

who  show  none  of  the  usual  stigmata  that  are  assigned  to  those 
suffering  from  this  disease.  The  old  teaching  that  any  man 
may  have  syphilis  has  its  counterpart  in  tuberculosis.  Any  man 
may  have  tuberculosis;  and,  when  it  is  present  in  its  early  stage 
at  the  time  when  it  is  most  curable,  the  patient  does  not  neces- 
sarily differ  in  his  appearance  from  other  members  of  society. 

History  of  Past  Illness. — Most  patients  who  present  for  exam- 
ination are  suffering  from  renewed  activity  in  an  old  focus  or 
from  an  extension  of  the  disease  to  new  areas.  Therefore,  it  is 
important  to  inquire  carefully  whether  the  patient  at  any  time 
during  his  previous  years  suffered  from  similar  symptoms.  It 
is  not  uncommon  for  the  patient,  after  a  little  reflection,  to  re- 
call previous  attacks  which  were  similar;  or,  to  recall  other 
symptoms  or  attacks  which  were  most  probably  associated  with 
previous  periods  of  activity  in  the  same  or  other  tuberculous  foci. 
A  previous  pleurisy,  or  tuberculous  bronchitis,  or  spitting  of 
blood  or  fistula  is  not  uncommonly  found  in  the  previous  history, 
antedating  the  present  illness  from  one  to  twenty  years. 

These  attacks  are  usually  characterized  by  other  names,  some- 
times through  ignorance  and  in  other  instances  with  intention  to 
deceive.  ' '  La  grippe, "  ' '  bronchitis, "  ' '  neurasthenia, "  ' '  anemia, ' ' 
"malaria,"  "a  run-down  condition,"  "intercostal  neuralgia," 
"bleeding  from  the  throat,"  are  terms  which  are  frequently  em- 
ployed in  comforting  and  lulling  the  patient,  who  is  suffering 
from  early  clinical  tuberculosis  into  false  security.  "We  can 
hardly  conceive  of  anyone  having  constantly  repeated  attacks 
of  la  grippe;  bronchitis  which  hangs  on  and  comes  frequently  is 
always  suspicious;  neurasthenia  demands  a  diagnosis  and  has 
tuberculosis  for  its  etiological  factor  oftener  than  is  generally 
believed;  malaria  should  not  be  confidently  assigned  as  the  cause 
of  the  general  lack  of  ambition  which  is  found  in  malarial  dis- 
tricts, for  these  patients  also  are  subject  to  tuberculosis  and 
other  diseases  which  cause  the  same  symptoms;  a  run-down  con- 
dition is  suggestive  of  many  things  but  demands  that  the  phy- 
sician search  until  the  true  cause  is  found,  and  if  repeated  or  at 
all  persistent  should  call  for  careful  search  for  tuberculosis; 
intercostal  neuralgia  is  frequently  diagnosed  when  pleurisy  of  tu- 
berculous origin  is  the  real  condition  present;  and  bleeding  from 


PRESENT  ILLNESS  365 

the  throat  is  the  sedative  which  throws  many  people  off  their 
guard  and  allows  an  early  tuberculosis  to  creep  on  to  an  ad- 
vanced hopeless  condition.  The  history  of  any  of  these  condi- 
tions during  the  past  life  of  a  patient  is  extremely  suggestive 
of  previous  attacks  of  active  tuberculosis. 

Slow  recovery  from  other  diseases  should  always  excite  suspi- 
cion. Some  of  the  common  symptoms  of  tuberculosis  will  usually 
appear  if  this  disease  is  present  and  careful  physical  examination 
of  the  chest  should  be  made.  The  tuberculin  test  cannot  always 
be  relied  on  under  the  circumstances.  If  positive  it  is  valuable ; 
but  if  negative,  it  should  be  accepted  with  great  reservation  (see 
page  504). 

Sometimes  a  definite  history  of  a  tuberculous  lesion  elsewhere 
in  the  body,  either  at  the  present  time  or  sometime  in  the  past 
can  be  obtained.  If  so,  it  should  not  bias  the  examiner,  but  cause 
him  to  be  careful  in  weighing  it  along  with  other  evidences. 

Present  Illness. — Hawes2  rightly  emphasizes  the  importance 
of  asking  the  patient  how  long  it  is  since  he  was  per- 
fectly well.  The  writer  has  found  this  of  great  importance. 
The  patient  does  not  know  when  he  became  ill  of  the  tubercu- 
lous process  because  the  symptoms  at  first  are  so  slight  that  he 
does  not  recognize  them  as  making  him  ill  until  the  early  stage 
has  passed.  In  answer  to  this  question,  however,  he  will  often  go 
back  weeks  or  months,  and  sometimes  even  years  before  he  finds 
the  time  when  he  really  felt  well.  Some  patients  will  be  unable 
to  give  any  history  of  previous  disease,  the  active  symptoms  com- 
ing on  without  warning.  This  sudden  explosive  type  of  tubercu- 
losis is  usually  overlooked;  coming  as  it  does  without  the  usual 
antecedent  history  of  being  run  down,  and  without  stomach  and 
nervous  manifestations,  tuberculosis  is  not  thought  of.  From 
the  marked  rise  of  temperature  present  it  is  often  called  typhoid, 
or,  if  the  lung  is  examined,  it  is  diagnosed  as  pneumonia  or  la 
grippe. 

Classification  of  Early  Symptoms. — The  symptoms  belonging 
to  tuberculosis  are  varied  and  appear  as  expressions  of  disturb- 
ance in  many  different  structures  and  organs.     When  analyzed, 


'Early  Pulmonary  Tuberculosis,  William  Wood  &  Company,  New  York,   1913. 


366 


DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 


however,  all  of  the  twenty  or  more  symptoms  can  be  classified 
according  to  their  etiology  in  three  groups  as  follows : 


Symptoms  Due  to 

Symptoms  Due  to 

Symptoms  Due  to 

Toxemia. 

Eeflex  Cause. 

Tuberculous  Process 
•per  se. 

Malaise 

Hoarseness 

Frequent  and  protracted 

Feeling     of    being     run- 

Tickling in  larynx 

colds 

down 

Cough 

Spitting  of  blood 

Lack  of  endurance 

Digestive   disturbances 

Pleurisy 

Loss  of  strength 

Loss  of  weight 

Sputum 

Nervous  instability. 

Circulatory  disturbances 

Temperature 

Digestive  disturbances 

Chest  and  shoulder  pains 

Loss  of  weight 

Flushing  of  face 

Increased  pulse  rate 

Apparent  anemia 

Night  sweats 

Temperature 

Blood  changes 

The  above  classification  was  first  published  by  the  author  in 
January,  1914.3  Since  that  time  I  have  made  slight  changes 
in  the  arrangement  of  the  symptoms.  By  so  grouping  the 
symptoms  we  gain  a  fuller  comprehension  of  the  disease  and 
grasp  the  situation  which  presents  with  greater  understanding. 

General  Characteristics  of  the  Toxic  Group. — It  will  be  noticed 
at  once  that  this  group  of  symptoms  is  expressive  of  central 
nerve  cell  stimulation;  that  its  action  is  that  of  general  inhibi- 
tion of  function;  that  the  symptoms  are  expressed  widely 
through  the  body;  and  that  when  taken  together,  they  form  the 
symptom-complex  which  is  particularly  expressive  of  a  general 
nervous  discharge  through  the  sympathetic  nervous  system.  It 
will  also  be  noted  that  this  group  of  symptoms  is  not  alone  char- 
acteristic of  tuberculous  toxemia.  It  can  as  well  be  an  expression 
of  an  infection  in  a  tonsil,  the  prostate,  the  fallopian  tube,  or  an 
intestinal  toxemia,  or  one  of  the  acute  toxemias,  as  of  tuber- 
culosis; consequently,  when  taken  alone  is  of  limited  value  as 
diagnostic  evidence  of  the  presence  of  active  tuberculosis. 

The  future  will  reveal  more  fully  the  relationship  be- 
tween the  toxic  state  and  the  secretion  from  the  ductless  glands. 
There  is  considerable  disturbance  in  glandular  functions.     The 


'Northwest  Medicine,  Jan.,   1914. 


TOXIC   GROUP   OF   SYMPTOMS  367 

adrenal  glands  are  supplied  by  branches  from  the  splanchnic 
group  of  the  sympathetics,  and  respond  with  increased  secretion 
when  the  sympathetics  are  stimulated.  Not  only  do  they  re- 
spond to  sympathetic  stimulation,  but  the  adrenin  when  circu- 
lating in  the  blood  stream  produces  inhibitory  action  of  the  same 
character  and  in  the  same  organs  as  that  produced  by  the  sym- 
pathetics. The  enlargement  of  the  thyroid,  as  frequently  ob- 
served during  early  clinical  tuberculosis,  suggests  that  this  gland 
is  probably  called  upon  for  extra  service  in  the  presence  of  in- 
fection. This  is  also  supported  by  its  enlargement  in  the  pres- 
ence of  other  infections. 

No  matter  how  the  symptoms  are  produced  or  what  it  is  that 
prolongs  them,  the  syndrome  of  toxemia  is  that  of  central  stimula- 
tion plus  general  discharge  through  the  sympathetic  nervous  system. 

The  symptoms  of  this  group  are  those  expressive  of  general 
inhibition  of  function  on  the  part  of  the  internal  viscera  and  are 
prolonged  by  such  states  as  pain,  anxiety,  fear,  discouragement, 
disappointment,  and  general  nervous  depression.  It  is  impor- 
tant to  bear  the  influence  of  the  depressive  emotions  in  mind  be- 
cause it,  at  times,  assumes  diagnostic  importance.  Tuberculosis 
is  not  a  disease  which  produces  a  continuous  noticeable  toxemia 
in  its  early  stages.  It  goes  through  periods  of  acute  activity 
now  and  then,  which  are  followed  by  periods  of  quiescence.  In 
the  early  stage,  and  up  to  the  time  that  softening  begins,  clini- 
cal tuberculosis  is  in  a  state  of  quiescence  in  by  far  the  greater 
portion  of  the  time.  And  even  then,  unless  the  area  of  softening 
be  a  large  one,  the  periods  of  quiescence  are  relatively  long. 

The  symptoms  belonging  to  the  toxic  group  should  pass  away 
when  the  acuteness  of  the  process  is  over ;  or  when  the  body  has 
established  an  ability  to  properly  counteract  these  toxic  in- 
fluences. When  either  of  these  states  has  been  reached,  however, 
toxemia  may  still  be  able  to  produce  its  symptom-complex  by 
faulty  methods  of  living  on  the  part  of  the  patient,  particularly, 
overexertion  with  its  attendant  increased  heat  production  and 
autoinoculation.  So  may  the  same  group  of  symptoms  be  pro- 
longed by  such  depressive  states  as  pain,  anxiety,  fear,  disap- 
pointment, and  discouragement. 


368  DIAGNOSIS    OF   EARLY   PULMONARY   TUBERCULOSIS 

So,  it  will  be  seen,  that,  while  this  group  of  symptoms  is  of 
great  importance  in  the  diagnosis  of  early  active  tuberculosis; 
yet  its  presence  alone  is  not  sufficient  to  make  a  diagnosis.  It 
must  be  accompanied  by  other  symptoms  and  other  signs.  It 
is  equally,  if  not  more,  important  to  remark  the  opposite  of  this — 
that  active  tuberculosis  may  be  present  without  the  presence  of 
the  symptoms  due  to  toxemia. 

It  is  of  greatest  importance  to  early  diagnosis  that  this  fact 
be  known.  To  that  end  let  us  recall  our  pathology.  Early  pul- 
monary tuberculosis  is  an  infiltration  in  the  lung  tissue.  The 
bacilli  are  embedded  in  the  tissues  and  are  surrounded  by  new 
cells.  The  process  becomes  acute  only  when  the  bacilli  multiply 
and  toxins  diffuse  into  the  adjacent  tissues.  If  this  process  is 
carried  sufficiently  far,  necrosis  takes  place.  This  necrosis  does 
not  involve  all  of  the  infiltrated  tissue,  but  only  a  circumscribed 
portion.  When  caseation  occurs,  as  it  so  often  does,  or  when  the 
process  has  subsided  without  caseation  taking  place,  the  acute 
symptoms  of  toxemia  disappear;  yet  the  same  pathological 
changes  may  soon  take  place  in  other  areas,  so  we  are  not  justi- 
fied in  looking  upon  the  process  in  any  other  manner  than  as  an 
active  one.  That  this  characterization  is  correct  is  usually  shown 
by  other  periods  of  acute  pathological  changes  with  attending 
toxic  symptoms  taking  place  after  intervals  varying  in  length 
from  a  few  days  to  weeks  or  months.  It  is  also  proved  by  the 
fact  that  the  symptoms  due  to  reflex  cause,  likewise  the  physical 
signs  due  to  the  same  cause,  continue  to  manifest  themselves  over 
periods  of  months  after  the  toxic  group  of  symptoms  has  dis- 
appeared. This  is  well  illustrated  in  the  cases  described  in  The 
Tuberculosis  Clinic,  Chapter  L,  Vol.  II. 

SYMPTOMS  DUE  TO  TUBERCLE  TOXINS. 

There  is  no  regularity  in  the  severity  of  the  symptoms  based 
on  toxemia  because  the  amount  of  toxins  differ  so  markedly  in 
different  patients  and  under  different  conditions.  "While  this 
can  be  more  readily  seen  in  advanced  cases  where  we  have  the 
two  forms,  acute  caseous  tuberculosis  and  the  slow  fibro-ulcera- 
tive  form,  it  is  also  evident  in  the  early  cases.    One  patient  will 


SYMPTOMS   DUE   TO   TUBERCLE  TOXINS  369 

suffer  greatly  and  show  most  of  the  symptoms  mentioned  in 
Group  I,  and  another  will  hardly  realize  that  he  is  ill  and 
scarcely  complain  at  all.  The  latter  patient  should  have  the  best 
chance  of  recovery,  for  the  inhibition  of  his  conservative  forces, 
as  produced  through  stimulation  of  the  sympathetic  nervous  sys- 
tem, is  less  marked,  or,  as  we  would  naturally  say,  his  disease  is 
less  severe.  This  advantage,  however,  is  too  often  sacrificed  by 
the  delayed  diagnosis  and  unwarranted  certainty  on  the  part 
of  the  patient,  either  that  he  is  not  ill  or  that  his  illness  is  so 
slight  that  he  will  recover  without  following  a  careful  routine. 

Malaise,  Nervous  Instability,  a  Feeling  of  Being  Run-down, 
and  Lack  of  Endurance. — These  are  common  symptoms  of  ac- 
tive tuberculosis.  They  are  particularly  expressive  of  the  ef- 
fect of  the  toxins  upon  the  central  nervous  system,  although  they 
may  be  caused  by  all  the  forces  which  tend  to  lower  the  pa- 
tient's vitality.  When  an  old  tuberculous  process  becomes  ac- 
tive, or  a  new  infection  occurs,  patients  are  very  apt  to  note  that 
they  tire  more  easily  than  formerly.  They  suffer  from  a  languor 
which  seems  unexplainable.  This,  at  times,  almost  amounts  to 
an  aching.  Patients  sometimes  feel  that  they  do  not  want  to 
move  or  be  disturbed,  and  yet  they  can  see  no  reason  for  it. 
Sleep  and  rest  do  not  refresh  them.  They  seem  to  have  an  in- 
definite feeling  due  to  what  is  to  them  an  inexplainable  cause. 
It  is  nothing  they  can  explain,  nothing  that  they  can  fully  grasp ; 
yet  there  is  a  consciousness  that  something  is  the  matter.  Some- 
times they  are  taken  to  be  lazy  by  their  friends,  and  even  believe 
it  themselves.  When  the  toxemia  is  very  severe  these  symptoms 
are  increased.  Speaking  of  languor,  Minor  well  puts  it:  "The 
whole  body  seems  filled  with  tiredness."  They  note  that  their 
disposition  is  changing.  They  are  irritable  and  more  easily  dis- 
turbed than  usual.  They  often  lose  ambition  and  assume  a 
"don't  care"  attitude.  It  is  such  an  effort  to  do  things  that  they 
find  themselves  neglecting  duties  which  they  have  always  as- 
sumed cheerfully. 

Tasks  which  were  formerly  easy  are  now  accomplished  with 
difficulty.  A  little  effort  is  followed  by  exhaustion  from  which 
recovery  is  slow.    The  patient  then  finds  himself  in  a  run-down 


370  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

condition,  a  state  of  low  vitality,  from  which  he  seems  unable  to 
pull  himself  together.  At  first  the  patient  does  not  feel  like 
doing;  later  he  cannot  do.  His  endurance  is  gone.  This  state 
is  often  diagnosed  as  neurasthenia.  To  be  sure,  neurasthenia  is 
present.  But  this  is  not  a  diagnosis.  Neurasthenia  has  a  cause. 
It  is  a  condition,  not  a  disease.  Tuberculosis  is  very  often  the 
cause  and  should  always  be  thought  of,  especially  if  any  other 
signs,  such  as  rise  of  temperature,  and  loss  of  weight,  and  particu- 
larly symptoms  belonging  to  the  other  groups,  are  present. 

Gastrointestinal  Symptoms. — The  toxic  symptoms  on  the  part 
of  the  gastrointestinal  tract  in  early  clinical  tuberculosis  mani- 
fest themselves  as  a  general  inhibition  of  action  in  all  the  func- 
tions of  the  alimentary  canal.  They  are  not  always  constant, 
nor  are  they  always  present  in  the  same  degree  of  severity,  yet 
there  is  nearly  always  present  some  degree  of  inhibited  action 
upon  the  functions  of  the  digestive  tube.  The  patient  may  note 
a  capricious  appetite;  or  the  appetite  may  be  absent.  At  other 
times  he  may  have  little  or  no  noticeable  disturbance.  During  the 
periods  when  the  toxemia  is  most  acute,  however,  there  is  usually 
at  least  a  slightly  coated  tongue,  a  deficiency  of  gastric  and  in- 
testinal juices  and  a  deficiency  of  gastric  and  intestinal  motil- 
ity, all  of  which  is  an  expression  of  general  sympathetic  disturb- 
ance. Loss  of  iveiglit  usually  follows  this  digestive  disturbance 
although  it  is  often  difficult  to  find  accurate  data  on  this  point 
as  people  do  not  weigh  regularly,  often  not  for  years.  In  early 
tuberculosis  this  loss  only  amounts  to  a  few  pounds.  When 
there  is  a  loss  of  fifteen  or  twenty  pounds  of  weight  as  a  result 
of  the  tuberculous  process,  it  indicates  that  the  disease  is  not 
early.  Such  a  loss  in  weight  must  have  a  severe  pulmonary  in- 
volvement back  of  it.  The  infection  is  either  very  virulent  or 
widespread,  or  both;  or  the  inhibited  function  may  be  due  to 
depression. 

It  is  particularly  important  for  those  who  are  attempting  to 
diagnose  early  tuberculosis  to  bear  in  mind  that  both  men  and 
women  attain  a  maximum  weight  for  their  early  years  when 
about  eighteen  or  twenty  years  of  age.  After  holding  this  a 
year  or  two  they  will  fall  back  five,  ten,  and  sometimes  fifteen 


SYMPTOMS  DUE   TO  TUBERCLE   TOXINS  371 

pounds  and  then  hold  this  as  their  normal  weight  until  after  the 
third  decade  has  been  reached.  It  is  very  important  to  bear  this 
in  mind  when  taking  histories  for  it  would  be  manifestly  er- 
roneous to  consider  this  maximum  as  the  normal  weight,  or  this 
loss  as  pathological.  Other  causes  for  loss  of  weight  must  al- 
ways be  considered.  This  symptom  has  no  value  unless  accom- 
panied by  others,  and  at  about  the  age  of  twenty  it  may  be  due 
to  the  natural  decrease  in  weight  which  I  have  just  mentioned. 

Night  Sweats. — In  our  attempt  to  offer  a  physiological  explana- 
tion of  the  sweating  which  occurs  in  tuberculosis,  we  are  con- 
fronted with  the  fact  that  there  is  still  an  uncertainty  in  the 
minds  of  physiologists  as  to  the  manner  in  which  sweating  is 
produced.  There  are  certain  facts  which  indicate  that  sweating 
is  at  times  due  to  stimulation  of  the  sympathetics,  and,  again,  to 
stimulation  of  the  greater  vagus.  It  accompanies  toxemia,  fear, 
rage,  and  other  symptoms  which  we  know  are  definitely  due  to 
sympathetic  stimulation.  On  the  other  hand,  sweating  is  found 
as  a  symptom  of  vagus  tonus.  It  is  also  relieved  by  atropin, 
which  is  the  physiological  antagonist  of  the  greater  vagus. 

The  muscles  of  the  sweat  glands  receive  their  innervation  from 
the  sympathetics,  and  when  stimulated  to  contraction,  are  able 
to  force  the  sweat  from  the  glands,  providing  it  is  already  pro- 
duced; but  we  do  not  believe  that  this  is  the  physiological  ex- 
planation of  sweating.  There  is  unquestionably  a  definite  in- 
nervation of  the  glands  themselves;  but  whether  this  comes  from 
the  sympathetic  or  greater  vagus  divisions  of  the  vegetative 
system,  or  both  (the  latter  seems  certain  from  clinical  observa- 
tion), will  have  to  be  determined  by  future  study.  In  tubercu- 
losis, sweating  is  an  accompaniment  of  the  state  of  toxemia. 

Rise  in  Temperature. — Rise  in  temperature  can  either  be  due 
to  bacillary  toxins  or  to  the  absorption  of  other  protein  from  the 
inflammatory  process  in  the  lung  itself.  It  is  probably  due  partly 
to  some  increase  in  metabolic  activity  resulting  in  increased  heat 
production,  but  far  more  to  an  interference  with  the  elimina- 
tion of  heat  when  formed. 

The  discussion  of  the  question  of  temperature  seems  more  ap- 
propriate  in  connection  with  the  study  of  advanced  tubercu- 


372  DIAGNOSIS   OF  EAELY  PULMONARY   TUBERCULOSIS 

losis ;  yet,  in  order  to  make  the  etiological  basis  of  this  symptom 
clear  it  should  be  discussed  at  this  time. 

That  a  rise  in  temperature  may  be  due  to  the  action  of  bacil- 
lary  toxins  as  well  as  to  the  tuberculous  process  per  se  seems 
evident.  To  explain  the  rationale  of  its  production,  however, 
is  not  so  simple.  For  years  my  study  has  led  me  to  look  upon 
the  rise  of  temperature  which  occurs  in  infections  in  general, 
as  a  conservative  process.4  It  is  an  index  to  the  reacting  powers 
of  the  patient.  This  may  be  seen  in  a  comparison  of  the  be- 
havior of  the  child  and  the  old  man  toward  the  same  infection, 
as  in  pneumonia.  The  child  has  a  high  fever  and  recovers,  the 
old  man  exhibits  a  temperature  of  100°  to  the  same  infection  and 
succumbs.  Crile5  considers  temperature  as  a  part  of  the  protec- 
tive mechanism  against  infection.  He  says:  "As  to  the  mechan- 
ism which  produces  fever  we  postulate  that  it  is  the  same  mechan- 
ism as  that  which  produces  muscular  activity.  Muscular  activity 
is  produced  by  the  conversion  of  latent  energy  into  motion,  and 
fever  is  produced  largely  in  the  muscles  by  the  conversion  of 
latent  energy  into  heat." 

I  will  not  enter  into  a  free  discussion  of  the  cause  of  fever  at 
this  time,  having  done  so  more  fully  in  Chapter  XXX,  Volume 
II.  It  is  necessary,  however,  if  possible,  to  make  plain  the  cause 
of  fever,  that  we  may  be  able  to  understand  the  value  of  this 
symptom  in  the  early  diagnosis  of  tuberculosis.  During  the  time 
when  tubercle  bacilli  are  multiplying  they  form  toxins  which 
find  their  way  into  the  blood  stream.  The  inflammation  in  the 
lung  also  causes  a  certain  chemical  activity  resulting  in  the  ab- 
sorption of  toxic  products.  The  destruction  of  these  toxins  is 
produced  by  chemical  action  which  results  in  an  increased  pro- 
duction of  heat.  These  toxic  products  also  act  upon  the  central 
nerve  cells.  They  exert  a  particular  action  upon  the  vasomotor 
center  and  produce  a  general  stimulation  of  the  entire  sympa- 
thetic system.  As  a  result,  we  find  vasoconstriction  as  a  part  of 
the  syndrome  of  toxemia.  As  a  result  of  the  extra  heat  produc- 
tion,  and  from  this  vasoconstriction    which    is    produced    by 


^Tuberculin  in  Diagnosis  and  Treatment,  C.  V.  Mosby  Co.,  St.  Louis,  1913,  Chapter  X. 
6The  Origin  and  Nature  of  the  Emotions,  W.  B.   Saunders  Co.,  Philadelphia,   1915. 


SYMPTOMS  DUE   TO   TUBERCLE  TOXINS  373 

toxemia,  there  results  a  heat  production  which  is  greater  than 
heat  elimination,  and  a  consequent  rise  in  temperature. 

This  increase  in  body  heat  tends  to  prevent  the  multiplica- 
tion of  bacteria  which  menace  the  organism  and  at  the  same  time 
favors  the  production  of  specific  defensive  substances.  Crile 
postulates  that  the  effect  of  pain,  emotions  such  as  fear  and 
anger,  and  infections,  is  all  one — that  of  bringing  into  activity 
the  latent  energy  of  the  body  and  converting  it  into  active  de- 
fense. The  process  is  the  same  whether  it  expresses  itself  in  a 
motion  to  escape,  or  in  an  attack  upon  an  antagonist,  or  in  the 
destruction  of  dangerous  toxins  by  oxidization  with  an  accom- 
panying rise  in  the  body  temperature  which  inhibits  the  growth 
of  the  invading  bacteria  from  which  the  toxins  arise.  This  ac- 
tion takes  place  through  the  brain,  adrenals,  liver,  thyroid,  and 
muscles,  the  organs  of  the  body  which  are  particularly  con- 
cerned in  the  transformation  of  latent  into  active  energy. 

A  carefully  constructed  temperature  curve  is  of  great  value 
as  an  aid  to  the  diagnosis  of  early  clinical  tuberculosis  during 
the  state  of  toxemia,  but  of  less  value  after  the  toxic  state  has 
passed.  This  cannot  be  emphasized  too  strongly.  If  other  sus- 
picious symptoms  are  present  and  a  carefully  constructed  tem- 
perature curve  is  characteristic,  and  a  tuberculin  test  should  prove 
positive,  the  reaction  reaching  its  maximum  early,  the  diagnosis 
of  probable  active  clinical  tuberculosis  should  be  made  even  in 
the  absence  of  physical  signs  on  percussion  and  auscultation. 

In  order  to  construct  a  temperature  chart  of  any  diagnostic 
value,  care  and  exactness  must  be  exercised.  A  carefully  con- 
structed chart  will  greatly  facilitate  the  study  of  temperature. 
It  is  very  difficult  to  secure  an  adequate  picture  when  the  tem- 
peratures are  taken  and  placed  in  columns  on  a  sheet  of  paper, 
but  when  a  graphic  chart  is  made,  the  picture  is  grasped  at  once. 
The  chart  should  be  made  of  four  daily  records,  and  should  in- 
clude both  the  maximum  and  minimum  for  the  given  patient  for 
the  day.  It  must  be  recalled  that  different  patients  will  reach 
their  minimum  and  maximum  temperatures  at  different  times 
of  day.  In  one  the  maximum  may  be  ten  or  eleven  o'clock  in 
the  morning,  though  this  is  rare.  Such  is  most  commonly  met  in 
those  who  begin  their  daily  activities  early.    It  might  be  at  two 


374 


DIAGNOSIS   OF  EARLY  PULMONARY  TUBERCULOSIS 


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376  DIAGNOSIS   OF  EAELY  PULMONARY  TUBERCULOSIS 

in  another  or  even  at  ten  or  eleven  o'clock  at  night.  My  plan, 
where  there  is  doubt,  is  to  have  a  two-hourly  chart  made  for  a  few 
days  until  I  can  see  at  what  time  the  maximum  temperature  ap- 
pears. I  then  choose  this  as  one  of  the  hours  of  the  day  when 
temperatures  are  to  be  recorded. 

I  wish  also  to  emphasize  the  importance  of  the  early  morning 
temperature.  If  one  will  observe  the  temperature  in  the  morn- 
ing when  the  patient  awakens  before  the  activities  of  the  day 
begin  he  will  have  a  very  important  starting  point  for  observa- 
tion. The  temperature  at  this  time  of  day,  depending  on  the 
time  that  it  is  taken,  should  be  from  97.2°  to  98°  F.  If  we  find 
the  temperature  98.6°  at  this  time,  it  is  probable  that  active  dis- 
ease is  present,  but  may  be  evidence  of  an  early  rise  of  normal 
temperature  for  the  individual  patient  as  shown  in  the  Figs. 
76  and  77.  The  normal  daily  variation  in  temperature  is  about 
one  and  a  half  degrees.  Unless  the  patient's  temperature  is  at 
this  low  point  in  the  morning,  he  is  suffering  from  a  constant 
rise.  It  is  not  sufficient  to  take  the  maximum  temperature  for 
the  full  study  of  the  fever  curve,  but  the  early  morning  tem- 
perature must  be  equally  considered  for  the  diurnal  variation  is 
of  value  in  determining  the  stability  of  heat  regulation.  I  usually 
construct  my  temperature  curve  from  that  taken  on  awakening 
in  the  morning,  twelve,  four  and  eight  o  'clock  unless  the  maximum 
should  fall  on  some  other  hour.  Fig.  113,  Vol.  II,  shows  a  normal 
temperature  curve  for  the  day,  while  Figs.  76  and  77  show  the  im- 
portance of  the  early  morning  record. 

There  are  many  sources  of  error  in  taking  temperature.  In 
the  first  place,  the  thermometer  should  be  held  in  the  mouth  suf- 
ficiently long  to  fully  register.  I  am  in  the  habit  of  requiring 
patients  to  hold  the  thermometer  a  minimum  of  five  minutes,  no 
matter  whether  it  be  a  one  minute,  two  minute,  or  three  minute 
thermometer.  If  the  weather  is  cold  and  the  cheeks  are  chilled, 
the  temperature  will  not  record  in  this  time.  The  thermometer 
must  sometimes  be  held  ten  or  fifteen  minutes  to  secure  a  full 
reading.  It  takes  ten  to  twelve  minutes  to  warm  the  mouth  if 
one  has  been  riding  in  the  cold  or  if  one  has  been  talking  in  the 
cold  air.    A  single  observation  made  at  the  time  of  the  visit  of 


TEMPERATURE  IN  DIAGNOSIS 


377 


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378  DIAGNOSIS   OF  EARLY  PULMONARY  TUBERCULOSIS 

the  patient  to  the  physician's  office  is  of  no  value  in  determining 
the  presence  or  absence  of  rise  in  temperature. 

The  patient  should  be  instructed  to  hold  his  mouth  closed  dur- 
ing the  entire  time  that  the  thermometer  is  registering.  Mouth- 
breathers  have  great  difficulty  in  registering  their  temperatures. 
In  fact,  mouth  temperature  in  a  mouth-breather  has  little  value. 
The  rectal  temperature  should  be  relied  upon  under  these  cir- 
cumstances. 

There  are  certain  peculiar  characteristics  of  the  temperature 
curve  that  should  be  considered. 

First:  Patients  suffering  from  active  tuberculosis  do  not  neces- 
sarily have  symptoms  of  toxemia  with  the  maximum  temperature 
above  normal  every  day  over  a  prolonged  period  of  time.  This 
toxemia  is  usually  inconstant  and  shows  waves  of  increase  and 
decrease.  The  patient  may  have  a  rise  of  temperature  above 
normal  for  a  period  of  a  week  or  more,  succeeded  by  a  like  period 
of  freedom  from  rise.  It  can  be  seen  that  if  the  temperature 
was  taken  during  the  period  of  acute  exacerbation  the  patient 
would  be  said  to  have  an  elevation  of  temperature.  However, 
if  it  were  taken  during  the  time  when  the  acuteness  of  the  tox- 
emia had  passed,  he  would  be  said  to  have  no  rise  of  temper- 
ature; consequently  it  is  impossible  to  .give  a  definite  opinion  of 
the  temperature  of  the  patient  in  whom  early  tuberculosis  is 
suspected  unless  the  chart  be  taken  for  a  period  of  two  or  three 
weeks.  This  point  is  well  illustrated  by  the  chart  in  Fig.  78. 
The  only  time  that  this  patient  showed  a  rise  in  temperature 
was  when  he  was  suffering  from  pleurisy,  the  lesion  being  a  sub- 
pleural  one.     (See  page  377.) 

Another  important  variation  to  be  noted  is  the  premenstrual 
rise.  This  elevation  of  temperature  varies  greatly.  In  some  in- 
stances it  will  be  extremely  regular,  the  temperature  running 
from  98.6°  to  99°  in  the  afternoon  for  the  two  weeks  prior  to 
menstruation  and  from  98°  to  normal  for  the  two  weeks  follow- 
ing menstruation.  In  others  the  elevation  of  temperature  will 
appear  only  a  week  or  a  few  days  before  the  menstrual  time. 
In  still  others  it  will  appear  during  the  period  and  continue  for 
a  short  time;  but  this  is  the  exception.  The  cause  of  this  most 
common  rise  in  the  temperature   curve  prior  to   menstruation 


TEMPERATURE  IN  DIAGNOSIS 


379 


1 


38C  DIAGNOSIS   OF  EAELY  PULMONARY  TUBERCULOSIS 

where  the  daily  maximum  amounts  to  little  more  than  one- 
half  of  one  degree  Fahrenheit,  we  must  look  for  in  something 
which  interferes  with  the  normal  elimination  of  heat.  This  we 
have  in  the  stimulation  of  the  vasoconstrictors  caused  by  the 
ovarian  secretion  produced  during  this  time,  as  discussed  more 
fully  on  page  195. 

More  marked  rises  in  temperature  which  occur  immediately 
preceding  or  during  the  period,  and  which  continue  through 
menstruation,  are  probably  associated  with  inflammatory  con- 
ditions in  the  genital  organs.  This  premenstrual  curve,  as  far 
as  I  have  been  able  to  determine,  appears  the  same  in  normal 
women  as  it  does  in  the  tuberculous,  although  I  have  had  only  a 
few  persons  who  were  able  to  keep  a  chart  for  me  sufficiently 
long  to  be  of  value;  yet  this  is  what  should  be  expected  on  phys- 
iological grounds. 

If  there  should  be  a  rise  in  the  temperature  curve  during  this 
premenstrual  time,  I  would  not  give  it,  of  itself,  any  diagnostic 
worth,  but  would  wait  and  take  the  temperature  again  follow- 
ing the  cessation  of  menstruation.  The  premenstrual  rise  is  shown 
in  Fig.  76,  in  which  it  will  be  seen  that  the  temperature  as  a 
whole  was  about  one-half  degree  higher  from  the  4th  to  the  17th 
of  the  month.  It  showed  a  slight  decline  on  the  17th,  the  18th 
being  the  first  day  of  menstruation.     (See  page  374.) 

Patients  can  readily  be  taught  to  take  their  own  temperature 
and  pulse  and  this  is  far  better  than  to  rely  on  the  irregular 
observations  made  by  the  physician  in  his  office.  From  one-half  to 
one  degree  should  be  allowed  for  nervousness  on  the  first  visit  to  the 
physician. 

A  very  annoying  temperature  curve  is  often  shown  by  those 
of  nervous  temperament.  It  is  characterized  by  irregularity, 
being  up  one  day  and  down  the  next.  While  this  character  of 
curve  is  often  met  with  in  the  tuberculous  patient,  the  irregu- 
larities are  not  primarily  due  to  the  tuberculous  process.  Fig. 
79  illustrates  this  rise  of  temperature.  Such  rises  of  temperature 
may  continue  in  nervous  individuals  for  months  after  the  dis- 
ease is  arrested.  It  is  often  difficult  to  convince  them  that  these 
rises  are  not  serious  and  that  they  are  not  caused  by  active  proc- 
esses.   The  probable  explanation  is  that,  through  the  action  on 


ACCELERATION   OF  PULSE  381 

the  nervous  system,  stimulation  of  the  vasoconstrictors  is  pro- 
duced which  interferes  with  the  elimination  of  heat. 

There  is  a  tendency  on  the  part  of  some  observers  to  go  too 
far  and  to  try  and  account  for  nearly  all  persistent  rises  of  tem- 
perature as  being  of  tuberculous  origin ;  but  when  other  suspicious 
symptoms  are  absent,  we  must  remember  that  infections  of  the 
tonsils,  teeth,  appendix,  and  genital  organs,  particularly  the 
prostate  and  fallopian  tubes,  or  infection  of  any  other  part  of 
the  body,  can  cause  an  elevation  of  the  temperature  curve.  Fig. 
80,  A  and  B,  shows  a  curve  in  a  patient  who  was  suffering  from 
chronic  inactive  tuberculosis  and  who  developed  a  tonsillitis.  A 
local  infection  remained  in  the  tonsil,  causing  the  temperature 
curve  here  shown.    (See  pages  382  and  383.) 

Acceleration  of  the  Pulse. — The  acceleration  of  the  pulse 
noted  during  early  active  tuberculosis  is  a  symptom  which  re- 
sults chiefly  from  the  disturbance  -  of  the  inspiratory  act  and 
from  the  effect  of  toxins  upon  the  sympathetic  nervous  system. 
The  degree  of  acceleration  of  the  pulse  in  early  tuberculosis 
varies  considerably  according  to  the  individual.  In  young  per- 
sons it  is  apt  to  be  greatest,  but  varies  considerably  according 
to  whether  the  patient  is  vagotonic  or  sympathetotonie,  accord- 
ing to  the  ideas  of  Eppinger  and  Hess.  After  the  symptoms  of 
activity  have  disappeared,  the  pulse  returns  to  a  normal  rate, 
or  the  degree  of  acceleration  is  lessened.  The  peculiar  charac- 
teristics of  the  pulse  in  early  tuberculosis  will  be  discussed  more 
fully  later  on  in  this  chapter  in  discussing  the  effect  of  reflex 
action;  but,  it  should  be  said  at  this  point  that  the  degree  of 
rapidity  of  the  pulse  is  the  resultant  largely  of  sympathetic 
stimulation  caused  by  toxemia  and  increased  output  of  adrenin 
on  the  one  hand,  and  reflex  stimulation  of  the  vagus  produced  by 
the  inflammation  in  the  lung,  on  the  other  hand.  During  periods 
of  toxemia,  sympathetic  stimulation  usually  predominates  and 
the  pulse  becomes  accelerated.  After  the  activity  has  passed 
by,  either  vagus  or  sympathetic  stimulation  may  be  most  marked 
according  to  the  individual.  If  one  should  expect  to  follow  the  ac- 
cepted teaching  that  acceleration  of  the  pulse  is  the  particular  char- 
acteristic of  active  tuberculosis,  he  could  go  wrong  in  the  majority 
of  instances,  because  acceleration  is  not  regularly  present  unless  the 
patient  is  depressed  or  overexerting. 


382 


DIAGNOSIS   OF  EARLY  PULMONARY  TUBERCULOSIS 


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383 


384  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

SYMPTOMS  OP  REFLEX  ORIGIN. 

Symptoms  of  reflex  origin  are  a  result  of  peripheral  stimula- 
tion of  the  pulmonary  ends  of  both  the  vagus  and  sympathetic; 
and,  inasmuch  as  the  action  of  these  two  divisions  is  antagonistic 
whenever  they  meet  in  the  same  organ,  one  time  the  symptom 
will  be  a  vagus  reflex,  at  another  time  a  sympathetic  effect. 

Another  peculiar  characteristic  of  the  symptoms  due  to  reflex 
action  is  that  they  all  point  away  from  the  lung.  Hoarseness, 
tickling  in  the  larynx  and  cough  point  to  the  larynx  as  the 
cause  of  the  trouble.  The  instability  of  the  heart  action  some- 
times points  to  the  heart.  The  gastrointestinal  disturbances  call 
attention  to  the  stomach  and  intestinal  tract,  while  pains  are 
very  apt  to  be  considered  as  rheumatic  or  neuralgic  in  origin. 
Thus,  it  can  be  seen  that  tuberculosis  masquerades  as  an  affec- 
tion of  each  one  of  the  great  systems  of  the  body;  sometimes 
symptoms  on  the  part  of  the  nervous  system  predominating,  some- 
times those  on  the  part  of  the  circulatory  system,  and  sometimes 
those  on  the  part  of  the  gastrointestinal  tract;  and  still  again, 
the  symptoms  may  point  to  the  upper  air  passages. 

In  my  discussion  of  the  vegetative  nervous  system  I  have  stated 
that  there  is  some  disagreement  in  the  minds  of  physiologists 
upon  the  point  of  reflex  sympathetic  action.  Some  physiologists 
maintain  that  there  can  be  no  reflex  action  resulting  from  af- 
ferent impulses  in  the  sympathetics  without  mediation  taking 
place  in  the  cord.  Others  claim  that  mediation  may  take  place 
in  the  sympathetic  ganglia.  If  this  latter  is  true,  we  can  have 
reflex  stimulation  produced  from  one  organ  to  another  with- 
out the  afferent  impulse  going  to  the  cord.  If  it  is  not  true,  such 
is  not  possible.  In  the  vagus,  afferent  impulses  go  back  to  the 
vagus  centers  and  can  be  reflected  in  other  branches  of  the  same 
nerve.  As  mentioned  elsewhere  in  these  pages,  it  seems  that 
there  are  disturbances  in  function  manifested  in  internal  viscera, 
when  one  vicus  is  involved,  which  indicate  that  we  do  have 
definite  sympathetic  reflexes  without  cord  mediation. 

In  order  to  understand  the  symptoms  of  reflex  origin  we  must 
bear  in  mind  that  wherever  the  sympathetic  and  greater  vagus 
nerves  meet,  their  action  is  antagonistic;  consequently,  we  have 


SYMPTOMS   OF  REFLEX  ORIGIN  385 

as  a  result  of  central  and  peripheral  stimulation  of  the  sympa- 
thetics  by  toxins  and  adrenin  an  action  which  is  antagonistic 
to  that  which  results  from  stimulation  of  the  vagus  by  the  in- 
flammation in  the  lung.  On  the  other  hand,  if  we  have  sympa- 
thetic reflexes  from  one  internal  viscus  to  another,  we  have  this 
influence  added  to  the  previously  mentioned  stimulation  to  counter- 
act the  vagus  reflex  action. 

"We  must  conceive,  in  studying  the  symptomatology  of  tuber- 
culosis, of  there  being  a  constant  force  at  work  to  disturb  the 
balance  between  the  vagus  and  the  sympathetic,  which  results 
now  in  increased  vagus  tonus,  and,  again,  in  increased  sympa- 
thetic tonus.  In  this  way  we  can  understand  the  variability  of 
the  symptoms  which  are  present  throughout  this  disease.  Not 
only  is  this  variability  present  in  tuberculosis,  but  it  is  present 
in  all  inflammatory  diseases  of  internal  viscera.  The  same  nerve 
influences  can  be  worked  out  for  each  disease. 

I  would  also  call  attention  to  the  fact  that  in  certain  individ- 
uals the  vagus  tone  naturally  predominates  over  the  sympathetic. 
In  such  individuals  vagus  symptoms  naturally  predominate.  In 
others  the  sympathetic  tonus  predominates  over  the  vagus.  Pa- 
tients in  the  first  class,  naturally  have  a  much  better  chance  of 
cure  than  those  in  the  latter  class  providing  the  tonus  is  not 
too  marked.  Marked  vagus,  the  same  as  marked  sympathetic 
tonus,  is  a  sign  of  unstable  nervous  mechanism  and  denotes 
lowered  resistance. 

The  symptoms  which  are  of  reflex  origin  are  not  constant.  For 
example,  we  may  have  hoarseness  at  one  time  and  not  at  another 
time.  We  may  have  a  rapid  heart  at  one  time  and  a  slow  heart 
at  another.  There  might  be  a  good  appetite  with  good  digestion 
at  one  time,  with  poor  appetite  and  slow  digestion  at  another, 
depending  on  which  division  of  the  nervous  system  predominates. 

Hoarseness. — Hoarseness  is  often  found  as  one  of  the  early 
symptoms  of  tuberculosis.  If  careful  inquiry  is  made  and  careful 
notice  is  taken  of  the  patient's  voice,  this  symptom  will  be 
found  to  be  present  in  early  tuberculosis  much  more  commonly 
than  is  generally  believed.  It  is  extremely  common  in  advanced 
tuberculosis,  particularly  during  periods  of  acute  activity  and 


586 


DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 


cavity  formation.  Complete  aphonia  lasting  for  a  few  days  is 
not  at  all  uncommon  at  this  time,  although  a  marked  degree  of 
hoarseness  is  more  apt  to  be  present.  In  early  cases  hoarseness 
is  slight  and  often  overlooked.  The  afferent  impulse  which  pro- 
duces hoarseness  travels  centralwards  through  the  pulmonary 
branches  of  the  vagus.  The  efferent  returns  through  either  the 
superior  or  recurrent  branch  of  the  vagus.  Where  the  afferent 
comes  through  the  superior  laryngeal  it  shows  as  a  relaxed  condi- 
tion of  the  cord,  an  inability  to  approximate  particularly  in  the 
center  because  the  interference  is  in  the  cricothyroid  muscle 
which  increases  the  tension  of  the  cords.  Where  the  efferent  im- 
pulse is  through  the  recurrent  laryngeal,  on  the  other  hand,  we 
have  an  apparent  adductor  paralysis,  which  shows  as  an  inter- 


Fig.  81. 


Fig.  82. 


Fig.  81. — Illustrating  schematically  the  inability  of  the  cords  to  approximate  in  the 
center  owing  to  disturbance  in  the  cricothyroid  muscle  because  of  reflex  interference  with 
its  innervation  through  the  superior  laryngeal  nerve. 

Fig.  82. — Illustrating  schematically  the  inability  of  the  posterior  end  of  the  cord  to 
approximate  its  fellow  because  of  interference  with  muscular  innervation,  through  the 
inferior  laryngeal  nerve. 

ference  in  adduction.  The  cord  involved  hangs  back  and  fails 
to  approach  its  fellow  in  the  center.  Both  of  these  types  of  dis- 
turbance in  the  cords  may  be  found  now  and  then  throughout  the 
course  of  the  disease.    They  are  illustrated  in  Figs  81  and  82. 

Tickling  in  the  Larynx  and  Dry,  Hacking  Cough. — These  are 
early  reflex  symptoms,  the  path  of  the  reflex  being  through  the 
laryngeal  branches  of  the  vagus.  The  afferent  impulse  being  due 
to  the  inflammation  in  the  lung  stimulating  the  vagus  fibers  and 
sending  afferent  impulses  centralwards  to  be  returned  through 
the  laryngeal  nerves. 


SYMPTOMS  OP  REFLEX  ORIGIN  387 

Unfortunately  these  symptoms  attract  attention  to  the  throat 
and  away  from  the  lungs.  These  unfortunate  reflexes  have  cost 
many  lives  by  misdirecting  both  the  patient  and  the  physician, 
the  true  source  of  the  cough  not  being  found  until  the  disease 
had  avanced  to  an  incurable  stage.  Uvulas,  tonsils,  and  ade- 
noids have  been  removed,  septums  straightened,  and  pharyngeal 
catarrh  treated  for  this  symptom,  when  a  chest  examination 
would  have  shown  that  the  trouble  was  below  the  larynx  in- 
stead of  above  it.  These  reflex  symptoms  on  the  part  of  the 
larynx  are  most  severe  during  periods  of  toxemia  when  the  in- 
flammation in  the  pulmonary  process  is  acute  and  the  periph- 
eral irritation  is  exaggerated.  Consequently,  we  would  ex- 
pect in  early  tuberculosis  to  find  some  of  the  toxic  symptoms  pres- 
ent when  tickling  in  the  larynx  and  cough  are  due  to  pulmonary 
tuberculosis.  If  not,  some  of  Group  III  might  be  present  to  give 
us  our  clue  to  the  localization  of  the  disease. 

Disturbance  in  Heart  Action. — There  are  peculiar  character- 
istic changes  in  pulse  rate  in  early  tuberculosis,  both  when 
toxemia  is  present  and  when  absent.  During  the  periods  when 
the  patient  is  suffering  from  toxemia  the  sympathetic  disturb- 
ances overbalance  the  vagus  in  nearly  all  instances  and  the  pa- 
tient has  rapid  heart  action ;  but  these  periods  of  toxemia  are  not 
constant.  Most  of  the  time,  the  patient  with  early  tuberculosis, 
is  comparatively  free  from  toxemia.  During  this  period  the  ac- 
tion of  the  heart  is  disturbed  reflexly  through  both  the  vagus 
and  the  sympathetic  (if  we  accept  the  view  that  sympathetic 
reflexes  may  be  mediated  in  ganglia  outside  of  the  cord) ;  stimu- 
lation through  the  vagus  attempting  to  inhibit  its  action  and 
slow  the  pulse,  and  stimulation  through  the  sympathetic  at- 
tempting to  accelerate  the  heart  action.  Which  one  predominates, 
depends  considerably  on  the  nerve  tone  of  the  individual,  as  men- 
tioned above.  This  antagonistic  action  between  these  two  divi- 
sions of  the  vegetative  nervous  system  is  constantly  going  on. 
When  the  patient  is  at  rest  and  free  from  toxemia  and  all  de- 
pressive states  such  as  those  of  anxiety,  discouragement,  and  dis- 
appointment, which  produce  general  sympathetic  stimulation  and 
increased  adrenin  secretion,  his  pulse  may  be  normal,  or  even 


388  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

below  normal.  Particularly  is  this  true  of  the  sthenic  individual. 
In  the  hyposthenic,  however,  there  is  more  apt  to  be  increased 
rapidity.  When  the  patient  begins  to  exercise,  however,  then 
the  pulse  becomes  more  rapid  than  would  be  normal  for  the 
particular  individual.  It  is  further  characteristic  of  the  pulse 
that  it  does  not  return  to  its  normal  rate  as  quickly  as  it  should 
after  it  has  become  accelerated.  The  peculiar  characteristics  of 
the  pulse  in  early  tuberculosis  are  produced  by  a  combination  of 
central  and  peripheral  stimulation  of  the  sympathetics  and  by 
reflex  stimulation  of  the  vagus  which  together  produce  a  resultant 
instability  the  degree  of  which  differs  in  different  individuals  and 
under  different  conditions.  It  may  be  slow  under  certain  con- 
ditions and  rapid  in  others.  It  may  be  rapid  in  one  individual 
and  slow  in  others,  as  fully  illustrated  in  Figs.  29,  page  200,  and  34, 
page  208. 

Disturbances  on  the  Part  of  the  Digestive  System. — Symp- 
toms of  reflex  origin  on  the  part  of  the  digestive  system  are  also 
variable.  During  periods  of  acute  toxemia  the  inhibitory  action 
of  the  sympathetic  nervous  system  prevails  in  most  instances, 
consequently  the  patient  shows  a  lack  of  appetite,  coated  tongue, 
a  deficiency  of  gastrointestinal  juices  and  an  inhibition  of  motil- 
ity. In  individuals  in  whom  the  sympathetic  tonus  predomi- 
nates over  the  vagus  tonus  this  may  be  more  or  less  constant  even 
during  periods  of  quiescence.  In  those  patients,  however,  of 
sthenic  build,  and  in  others  in  whom  we  might  expect  a  pre- 
dominance of  the  vagus  tonus,  we  are  apt  to  have  during  periods 
of  quiescence  an  increase  in  appetite,  increase  in  the  gastroin- 
testinal secretions  and  hypermotility,  even  to  the  point  of 
slowing  of  the  intestinal  contents  and  spasticity  of  the  colon. 

Loss  of  Weight. — This  is  more  apt  to  occur  as  a  result  of 
toxemia  than  reflex  action.  It  is  when  the  sympathetic  tonus 
predominates  over  the  vagus  tonus  that  we  have  the  greatest  dis- 
turbance in  the  gastrointestinal  tract  followed  by  marked  loss 
of  weight;  and  this  is  most  common  when  central  sympathetic 
stimulation  is  added  to  the  peripheral  irritation.  Increased  vagus 
tonus  will  at  times  also  cause  loss  of  weight. 

Chest  and  Shoulder  Pains. — A  symptom  which  should  receive 
more  attention  than  is  now  given  it  is  the  reflex  chest  and  shoul- 


SYMPTOMS   OF   REFLEX  ORIGIN  389 

der  pains.  These  present  two  characteristics.  One  of  these,  the 
reflex  sensory  disturbance  expresses  itself  particularly  on  the 
surface  in  the  third  and  fourth  cervical  and  third  to  fifth  thoracic 
zones  as  shown  by  Head  (see  Figs.  27  and  28,  pages  182  and  183). 
This  gives  pain  over  the  apices  of  the  lungs,  over  the  third  to 
fifth  interspace  anteriorly,  and  in  the  scapular  region  posteriorly. 
The  other  type  of  pain  is  that  which  seems  to  be  a  definite 
neuritis  affecting  the  branches  of  the  cervical  nerves  which  take 
their  origin  from  cells  in  the  cervical  segments  of  the  cord  which 
are  adjacent  to  and  in  communication  with  other  cells  receiving 
afferent  impulses,  through  the  sympathetics,  from  the  inflamed 
lung.  This  last  type  of  pain  requires  for  its  production  that  the 
disease  be  an  old  one  and  that  the  irritation  be  kept  up 
over  a  sufficiently  long  time  to  produce  degenerative  changes  in 
the  nerve  itself.  The  sensory  reflex,  however,  may  be  due  to  a 
new  involvement  or  to  activity  in  an  old  one.  Patients  often 
speak  of  these  pains,  particularly  the  shoulder  pains,  as  rheu- 
matism ;  and  they  are  often  so  considered  by  the  physician.  They 
vary  from  a  slight  ache  to  a  pain  of  severe  degree,  but  are  usu- 
ally only  moderately  severe.  In  taking  histories  it  is  always  well 
to  ask  the  patient  whether  he  has  had  rheumatism  or  neuralgia 
in  the  shoulders  or  chest  and  he  will  often  reply  that  he  has. 
It  will  frequently  be  found  to  involve  the  side  where  there  is  an 
old  process.  Pain  is  also  frequently  due  to  an  inflammation  of  the 
intercostal  nerves  which  extends  from  the  inflamed  and  thickened 
pleura.  This  is  probably  a  cause  of  apical  pains  in  limited 
lesions. 

Flushing  of  the  Face. — This  symptom  is,  as  a  rule,  not  pres- 
ent in  truly  early  tuberculosis.  It  requires  a  certain  amount  of 
involvement  before  it  is  present.  A  feeling  of  heat  in  the  cheek 
is  complained  of  at  times  by  patients  with  a  fairly  early  process ; 
but  is  usually  confined  to  the  periods  when  the  disease  is  dis- 
tinctly active.  It  is  due  to  a  reflex  dilatation  of  the  blood 
vessels  of  the  face,  head  and  ear;  the  irritation  causing  it  pass- 
ing through  the  superior  sympathetic  ganglion,  the  fibers  arising 
from  the  second  to  fourth  and  through  the  third  cervical  thoracic 
segments  of  the  cord;  it  is  confined  to  the  side  on  which  the 


390  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

activity  is  present,  or,  if  both  sides  are  involved,  it  is  usually 
most  marked  on  the  side  of  the  more  active  involvement. 

SYMPTOMS  DUE  TO  THE  TUBERCULOUS  PROCESS 

ITSELF. 

There  are  but  few  symptoms  which  are  due  to  the  tuberculous 
process  itself,  but  these  are  most  distinctive  of  all  symptoms 
present  in  early  clinical  tuberculosis.  Unfortunately,  they  are 
somewhat  later  in  appearing  than  some  of  those  of  the  other 
groups.  They  presuppose  either  an  involvement  of  some  duration 
or  one  of  considerable  extent.  In  fact,  when  we  make  a  diagnosis 
of  clinical  tuberculosis  it  has  really  existed  for  some  time  and 
there  is  also  a  considerable  area  involved.  The  symptoms  due 
to  the  tuberculous  process  itself  should  rarely  be  mistaken  for 
any  other  disease  or  condition. 

Frequent  and  Protracted  Colds. — So-called  frequent  and  pro- 
tracted colds  are,  as  a  rule,  tuberculous  bronchitis.  The  patient 
complains  of  taking  cold  easily  or  of  colds  which  hang  on  longer 
than  they  should.  Inquiry  will  usually  show  that  these  are 
not  the  ordinary  attacks  of  coryza.  If  they  begin  as  head  colds, 
they  end  up  with  a  cough;  but  are  usually  due  to  a  bronchitis 
from  the  beginning.  Such  attacks  should  always  be  viewed  with 
suspicion;  and,  if  accompanied  by  temperature,  or  other  symp- 
toms due  to  toxemia,  or,  by  those  belonging  to  the  reflex  group, 
should  call  for  a  careful  examination  of  the  chest.  When  these 
attacks  are  more  severe,  the  patient  calls  them  "la  grippe"  and 
speaks  of  having  one  attack  of  "la  grippe"  after  another.  Re- 
peated winter  coughs  are  often  of  this  type.  One  of  the  most 
important  things  to  understand  about  tuberculosis  is  that  none 
of  the  symptoms  are  necessarily  constant.  The  toxic,  or  even  the 
reflex  symptoms  following  one  of  these  definite  outbreaks  may 
soon  pass  away.  Activity  in  the  whole  process  may  clear  up  and 
show  no  further  symptoms  for  months,  or  even  for  years,  yet 
be  of  a  tuberculous  nature.  Symptoms  disappear  long  before 
the  process  is  pathologically  healed. 

Spitting  of  Blood. — This  indicates  tuberculosis  in  every  in- 


SYMPTOMS  DUE   TO   THE   TUBERCULOUS  PROCESS  391 

stance  unless  it  can  be  definitely  proved  otherwise.  While  there 
are  other  causes  for  this  symptom,  yet  the  fact  that  the  patient 
raises  blood  is  presumptive  evidence  that  tuberculosis  is  present ; 
and,  the  evidence  is  conclusive  in  most  cases  when  the  blood  is 
bright  and  mixed  with  sputum.  Pinkish  colored  saliva  some- 
times comes  when  the  gums  are  bleeding;  occasionally  we  find 
streaks  of  blood  in  the  presence  of  bronchitis ;  bloody  expectora- 
tion may  come  from  heart  lesions;  but  the  clinician  must  know 
that  these  causes  are  rare  in  comparison  with  the  one  great  cause 
of  blood  spitting, — tuberculosis.  If  the  examiner  will  look  for 
pulmonary  tuberculosis  in  all  such  cases  he  will  not  go  far  wrong. 
If  he  cannot  find  the  evidence  himself  it  is  his  duty  to  make  a 
probable  diagnosis  and  call  the  assistance  of  some  expert  diag- 
nostician. Vicarious  menstruation  is  often  spoken  of.  Per- 
sonally, I  have  never  seen  spitting  of  blood  at  the  menstrual 
time  except  in  the  tuberculous  patient.  Women  who  are  tuber- 
culous often  spit  blood  at  this  time.  If  there  is  one  symptom 
of  early  tuberculosis  that  should  always  be  interpreted  in  the 
interest  of  the  patient,  it  is  spitting  of  blood.  Blood  spitting  is 
not  always  preceded  by  other  symptoms,  nor  is  it  always  fol- 
lowed by  them.  It  may  be  due  to  tuberculosis  and  yet  be  the 
only  symptom  present.  This  would  occur  where  an  old  inactive 
lesion  had  ruptured,  causing  laceration  of  a  small  blood  vessel, 
and  then  healed  at  once  without  producing  any  extension  of  the 
disease. 

Pleurisy. — Pleurisy  is  another  symptom  which  should  not  be 
mistaken.  We  have  been  grossly  negligent  of  this  symptom  in 
the  past.  Pleurisy  has  a  definite  meaning.  In  a  very  large  per 
cent  of  cases  it  is  subpleural  tuberculous.  It  is  evidence  of  active 
tuberculosis.  The  profession  must  learn  that  tuberculosis  of  the 
pleura  is  as  serious  as  tuberculosis  of  any  other  organ,  with  the 
exception  that  it  is  limited  in  extent  and,  if  properly  regarded, 
offers  the  patient  a  chance  for  cure.  Pleurisy  is  a  metastasis  from 
some  other  focus  in  the  body  which  must  be  active  or  the  metas- 
tasis would  not  occur;  consequently  it  shotdd  be  treated  seriously. 
If  the  fact  that  there  is  an  involvement  in  the  pleura  is  not 
of  sufficient  consequence  in  the  mind  of  the  practitioner,  the  fact 
that  this  is  the  extension  from  some  other  focus  which  is  active 


392  DIAGNOSIS    OF   EARLY   PULMONARY   TUBERCULOSIS 

or  the  extension  could  not  have  occurred,  should  be  of  sufficient 
consequence  to  cause  this  symptom  to  be  treated  seriously.  This 
symptom  should  make  a  diagnosis  of  itself  unless  it  can  be  defi- 
nitely proved  that  the  pleurisy  has  some  other  cause.  This  applies 
to  dry  pleurisy  as  well  as  to  pleurisy  with  effusion.  As  a  rule, 
however,  symptoms  in  Group  I  will  manifest  themselves  during 
this  time  and  some  of  those  in  Group  II  will  undoubtedly  be 
present. 

Sputum. — "While  sputum  is  not  a  common  accompaniment  of 
early  tuberculosis  yet  it  is  present  more  often  than  we  suspect. 
Whenever  the  pathological  process  is  extending,  it  causes  an 
exudation  in  the  adjacent  tissues  and  there  may  be  a  slight 
amount  of  sputum  present.  At  first  this  may  be  only  mucous, 
but,  sooner  or  later,  ulceration  and  caseation  of  small  tubercles 
may  occur  and  bacillus-bearing  sputum  be  found.  Sputum 
should  always  be  examined.  It  is  best  to  give  the  patient  a 
bottle  and  require  him  to  bring  all  the  sputum  which  he  raises 
for  twenty-four,  forty-eight,  or  even  seventy-two  hours.  This 
sputum  should  be  treated,  not  only  according  to  the  ordinary 
methods  of  examination,  but  by  antiformin  or  digestion  and 
homogenization,  as  described  in  Chapter  XX.  If  this  course  is 
carefully  followed  one  will  often  be  surprised  at  finding  bacilli 
where  unsuspected.  The  inexactness  of  basing  a  diagnosis  .upon 
the  examination  of  a  single  sample  can  be  understood  if  we 
realize  that,  while  the  patient  may  expectorate  six  or  eight  times 
a  day  he  may  not  expectorate  bacilli  more  than  once  in  the  entire 
twenty-four  hours,  or  once  in  two  or  three  days;  hence,  the  ex- 
amination of  a  sample,  unless  bacilli  are  found,  is  worthless. 
Where  bacilli  are  not  found  the  lymphocyte  count  should  be 
noted.  In  tuberculous  sputum  there  is  often  a  high  lymphocyte 
count.  If  40  or  50  per  cent  of  lymphocytes  should  be  found  it 
should  be  considered  suspicious  of  tuberculosis.  Some  of  the 
other  symptoms  are  nearly  always  present,  so  the  diagnosis 
should  rarely  be  missed. 

Temperature. — Temperature  is  not  only  caused  by  tubercu- 
lous toxemia  as  previously  mentioned,  but  it  is  due  to  the  ab- 
sorption of  non-tuberculous  toxic  products  from  the  inflamed 


SYMPTOMS  DUE   TO   THE   TUBERCULOUS  PROCESS  393 

tissues.  Wherever  there  is  inflammation  there  is  absorption  of 
toxic  substances.  Resulting  from  their  destruction  there  is  an  in- 
creased chemical  action  and  increased  heat  production  and  at 
the  same  time  the  toxic  products  cause  vasoconstriction  inter- 
fering with  heat  elimination  and  produce  an  increase  in  tempera- 
ture. An  elevation  of  temperature,  particularly  if  it  is  accom- 
panied by  some  of  the  group  of  symptoms  of  reflex  origin  de- 
scribed above,  should  be  carefully  considered  in  its  relationship 
to  the  early  diagnosis  of  tuberculosis. 

RELATIVE  VALUE  OF  THE  VARIOUS  GROUPS  OF 
SYMPTOMS. 

From  the  preceding  discussion  it  will  be  seen  that  of  all  the 
symptoms  which  are  associated  with  early  tuberculosis,  there  are 
only  the  first  four  in  Group  III  which  point  directly  and  definite- 
ly to  the  lung.  By  understanding  the  causes  underlying  these 
three  groups  of  symptoms  we  can  nearly  always  pick  out  one 
or  more  belonging  to  each  group  when  early  active  tubercu- 
losis is  present.  This  combination  will  give  us  sufficient  evidence 
on  which  to  base  a  probable  diagnosis;  and  when  considered 
along  with  the  physical  signs  which  are  present  there  should 
be  comparatively  little  doubt  left  in  the  examiner's  mind  as  to 
whether  early  clinical  tuberculosis  is  or  is  not  present.  This 
subject  is  discussed  more  fully  in  Chapter  XXI. 


CHAPTER  XV. 

THE    DIAGNOSIS    OF    EARLY    PULMONARY    TUBERCU- 
LOSIS: PHYSICAL  EXAMINATION  OF  THE  PATIENT. 

General  Considerations. — There  is  no  best  method  of  examin- 
ing a  patient  that  is  applicable  to  all  examiners.  Different  men 
work  in  different  ways.  One  will  develop  a  peculiar  phase  of 
physical  examination  so  that  he  comes  to  rely  on  it,  while  an- 
other will  rely  most  on  another.  One  will  follow  some  particu- 
lar method  and  become  wedded  to  it,  while  another  will  utterly 
fail  in  its  application.  So  we  are  led  to  believe  that  it  is  not 
wholly  the  method  of  the  examiner,  but  rather  his  knowledge 
of  conditions  and  the  manner  in  which  he  interprets  his  data, 
the  judgment  which  he  uses,  that  makes  for  a  correct  diagnosis. 

Favorable  Conditions  for  Making  Examination  Important. — 
The  diagnosis  of  early  clinical  tuberculosis  depends  on  little 
things.  The  symptoms,  for  the  most  part  are  not  severe  and 
would  be  considered  unimportant  were  they  not  attributable  to 
so  serious  a  disease.  The  changes  in  physical  signs  are  often  so 
slight  that  they  are  only  appreciable  upon  careful  painstaking 
observation.  This  makes  it  essential  that  the  conditions  under 
which  an  examination  is  to  be  made  should  be  as  favorable  as 
possible. 

The  patient  should  be  examined  in  a  warm  room  so  that  he 
will  be  comfortable  and  relaxed.  The  difference  between  exam- 
ining through  relaxed  and  rigid  tissues  must  be  considered  in  all 
instances  and  will  be  dwelt  upon  more  as  our  discussion  proceeds. 

Nervousness  on  the  part  of  the  patient  should  be  allayed  if 
possible.  The  patient  should  be  stripped  to  the  waist.  The 
waist  should  be  free  to  allow  an  unobstructed  movement  of  the 
diaphragm  and  an  unobstructed  view  of  the  chest  when  in 
motion.  Inspection,  palpation,  percussion  and  auscultation  are 
all  practiced  with  greater  ease  and  greater  precision  when  the 
chest  is  bare. 


FAVORABLE   CONDITIONS   FOR  EXAMINATION  395 

Whenever  possible  the  patient  should  be  examined  in  a  sit- 
ting posture.  The  percussion  note  is  different  when  the  pa- 
tient is  lying  down  from  what  it  is  when  he  is  sitting  up,  be- 
cause we  not  only  percuss  the  chest  but  the  couch,  bed  or  stool 
that  the  patient  is  sitting  or  lying  on,  as  I  shall  describe  later. 
The  auscultatory  sounds  also  differ  when  the  patient  lies  down 
and  sits  up  because  the  type  of  breathing  changes.  The  sounds 
at  the  apex  are  accentuated  when  the  patient  is  examined  in  a 
sitting  posture.  Another  reason  why  the  sitting  posture  is  pref- 
erable is  because  the  examiner  is  more  comfortable  and  can 
make  a  better  examination.  Difficulties  are  much  increased  by 
bending  down  over  a  patient  in  bed.  It  is  best  for  the  patient 
to  sit  on  a  stool  without  a  back,  the  seat  being  a  few  inches 
higher  than  the  stool  of  the  examiner.  This  permits  a  favorable 
view  of  the  entire  chest  and  particularly  of  the  motion  of  the 
bases.  The  patient  should  face  the  light.  Daylight  is  prefer- 
able to  artificial  light.  The  differences  in  the  musculature  and 
soft  tissues  can  be  determined  very  much  better  and  it  always 
seems  to  me  that  I  can  note  the  changes  in  motion  better  with 
natural  than  artificial  light.  Whether  this  is  because  of  the  nat- 
ural light  being  more  intense  or  whether  the  fact  that  it  is  a 
white  light  while  artificial  light  is  nearer  the  tones  of  the  skin, 
I  am  not  sure. 

Methodical  Examination  Necessary. — Early  tuberculosis  may 
be  overlooked  by  not  examining  methodically.  There  are  cer- 
tain parts  of  the  chest  which  should  be  examined  more  carefully 
than  others  but  every  portion  should  be  included  in  the  ex- 
amination. Each  examiner  should  develop  for  himself  a  certain 
routine  which  includes  a  complete  investigation  of  the  appear- 
ance of  the  patient  as  a  whole,  and  the  chest  in  particular;  the 
condition  of  both  the  soft  parts  and  bony  thorax;  the  move- 
ments on  respiration;  the  resistance  of  the  chest  both  on  pal- 
pation and  percussion;  the  alterations  in  pitch  and  in  the  qual- 
ity of  the  note,  and  the  variations  in  auscultatory  findings.  The 
heart  should  always  be  included  in  an  examination  for  pulmon- 
ary tuberculosis. 

The  apices,  being  portions  of  the  lungs  which  are  usually  af- 


396  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

fected  when  our  advice  is  sought,  should  be  examined  most  care- 
fully. If  nothing  is  found  in  the  apices,  although  we  are  led 
by  the  clinical  history  to  believe  that  a  tuberculous  infection  is 
present,  we  must  not  forget  the  possibility  of  hilus  infection. 
The  bronchial  glands  are  usually  harbingers  of  the  early  in- 
fections and  it  is  not  uncommon  to  find  an  extension  of  the  dis- 
ease out  into  the  adjacent  pulmonary  tissue.  The  interscapular 
area  above  the  level  of  the  sixth  dorsal  vertebra  and  the  areas 
along  the  sternum  and  border  of  the  heart  should  be  carefully 
examined  in  such  cases.  In  fact,  one  must  be  ready  for  any  sur- 
prise, as  far  as  localization  is  concerned,  for  the  bacilli  might 
find  lodgment  and  start  an  active  process  in  any  portion  of  the 
lung.  The  difficulties  in  making  a  satisfactory  physical  exami- 
nation of  the  tissues  near  the  hilus  must  be  borne  in  mind,  and  the 
x-ray  should  be  utilized  When  possible. 

Negative  evidence  on  physical  examination  should  not  be  too 
hastily  interpreted  as  showing  absence  of  disease,  for  it  may 
be  only  proof  of  our  inability  to  find  the  infection. 

Physician's  Duty  in  Suspected  Cases. — In  case  physical  exam- 
ination fails  to  reveal  a  lesion  and  yet  the  examiner  believes  from 
the  clinical  history  that  tuberculosis  is  present,  it  is  his  duty  to 
tell  the  patient  frankly  what  he  suspects  so  that  he  may  regulate 
his  life  accordingly.  It  is  not  necessary  to  frighten  him.  In 
fact,  this  should  be  avoided.  When  early  tuberculosis  is  pres- 
ent or  when  it  is  suspected  is  the  time  when  the  physician  has 
a  great  responsibility  upon  him;  for,  depending  on  the  manner 
in  which  he  handles  the  situation,  hangs  the  life  and  usefulness 
of  the  patient.  The  shock  of  learning  of  a  suspected  infection 
can  be  taken  away  by  telling  the  patient  of  the  hopeful  side  of 
the  disease.  It  is  well  to  state  that  it  is  only  neglected  tubercu- 
losis that  kills,  but  that  early  lesions  will  usually  heal,  provid- 
ing the  patient  faces  the  situation  bravely  and  cooperates  in 
the  treatment. 

Etiological  Classification  of  the  Changes  Found  on  Physical 
Examination. — The  symptoms  in  early  tuberculosis  may  be 
divided  according  to  their  etiology  into  those  due  to  toxemia; 
those  of  reflex  origin;  and  those  due  to  the  tuberculous  process 


CLASSIFICATION   OF  PHYSICAL  SIGNS 


397 


per  se,  as  mentioned  in  the  preceding  chapter.  The  physical  signs 
may  be  divided  according  to  their  etiology  into  two  groups; 
those  of  reflex  origin  and  those  due  to  the  tuberculous  process  per 
se,  as  follows: 


Physical  Signs  in  Early  Tuberculosis 


OF  REFLEX   ORIGIN 


DUE  TO  TUBERCULOUS  PROCESS  per  se* 


Dilatation  of  the  pupil. 

Interference  with  approxi- 
mation of  vocal  cords. 

Lagging  of  chest  wall,  re- 
gional  and   general. 

Eigidity  of  muscles  (spasm). 


Increased  density  of  tissue  on  palpation. 
Increased  resistance  to  finger  on  percussion. 
Alteration  in  quality  and  pitch  of  percussion 

note. 
Alteration     in     inspiratory     and     expiratory 

rhythm. 
Alteration   in   strength,  quality   and   pitch   of 

respiratory  sounds. 
Adventitious  sounds   (rales). 


*A11  physical  signs  due  to  the  tuberculous  process  per  se  are  modified  by  whatever 
changes  are  found  in  the  soft  parts  and  bony  thorax.  The  amount  of  subcutaneous  tissue 
and  muscle  substance  covering  the  chest  must  be  considered;  so  must  the  condition  of 
these  tissues,  whether  the  subcutaneous  tissue  is  in  normal  amount  and  of  normal 
elastic  texture  or  atrophied;  and  whether  the  muscles  are  normal  in  size  and  texture 
or  in  a  state   of  increased  tone   (spasm),   or  in  a  state  of  atrophy. 

Factors  Causing  Changes  on  Inspection,  Palpation,  Percussion 
and  Auscultation. — The  careful  diagnostician  arrives  at  his  diag- 
nosis by  a  process  of  reasoning.  The  methods  of  deriving  data 
on  physical  examination  of  the  chest  follow  the  laws  of  physics, 
and  he  who  can  interpret  these  best  will  be  most  successful  in 
physical  diagnosis. 

When  we  make  a  physical  examination  of  the  chest  of  an  in- 
dividual suffering  from  clinical  tuberculosis  we  are  attempting 
to  determine  the  physical  changes  which  have  occurred  as  a  re- 
sult of  the  infection,  both  directly  and  remotely.  These  changes 
are  made  evident  to  us  through  our  senses  of  sight,  touch  and 
hearing  and  are  determined  by  inspection,  palpation,  percussion 
and  auscultation.  They  manifest  themselves  not  only  in  altera- 
tions of  the  pulmonary  tissues,  but  in  changes  of  the  soft  tis- 
sues covering  the  bony  thorax  and  in  the  bony  thorax  itself. 

The  physical  examination  for  early  clinical  tuberculosis  was 
long  considered  as  being  a  process  of  determining  the  depar- 
tures from  the  normal  in  sounds  heard  on  percussion  and  auscul- 


398  DIAGNOSIS   OP  EARLY  PULMONARY   TUBERCULOSIS 

tation,  as  a  result  of  the  tuberculous  infiltration  in  the  lung. 
Practically  everything  was  excluded  from  the  mind  except  the 
thickening  of  the  lung  tissue  and  the  way  it  affected  the  per- 
cussion and  auscultatory  note,  although  the  change  in  vocal 
fremitus  was  noted  by  some.  Later  it  was  found  that  this  thick- 
ening of  the  lung  tissue  was  also  perceptible  to  the  fingers  dur- 
ing percussion,  and  that  there  was  a  deficiency  in  the  respiratory 
movements  over  the  apex  in  which  the  infiltration  was  situated. 
But  this  conception  is  still  too  restricted. 

Our  attention  has  been  centered  too  much  on  the  changes  in 
the  tissue  per  se  and  not  enough  on  the  surrounding  structures. 
The  elements  which  make  up  the  sensation  conveyed  to  the 
fingers  on  palpating  or  percussing  the  chest  and  those  which 
are  conveyed  to  the  ear  on  percussing  and  auscultating  the  chest 
are  several  in  number;  the  infiltration  itself;  the  tissues  sur- 
rounding it,  pulmonary,  cardiac,  mediastinal,  and  pleural;  the 
tissues  covering  the  bony  cage,  and  the  cage  itself.  The  tissues 
within  the  thorax  are  often  influenced  by  changes  which  have 
resulted  from  previous  or  other  present  pathological  conditions. 
The  percussion  note,  particularly  if  heavy  stroke  is  used,  is  also 
greatly  influenced  by  the  patient's  surroundings,  whether  he  is 
sitting  on  a  soft  bed  or  a  solid  stool  or  standing  on  a  solid  floor. 
Palpation,  percussion  and  auscultation  are  influenced  markedly  by 
the  thickness  and  tone  of  subcutaneous  tissue  and  muscles. 

Factors  Which  Affect  Soft  Structures  Covering  the  Bony 
Thorax. — The  findings  obtained  on  physical  examination  differ 
greatly  according  to  the  amount  of  soft  tissues  covering  the  bony 
thorax,  whether  the  muscles  are  large  or  small  and  whether  there 
is  a  great  or  small  amount  of  subcutaneous  tissue.  It  also  dif- 
fers according  to  the  density  of  these  tissues;  therefore,  accord- 
ing to  whether  the  muscles  are  in  a  state  of  contraction  (spasm) 
or  relaxation,  whether  the  muscles  are  of  normal  texture  or  de- 
generated. The  writer  first  called  attention  to  the  diagnostic  im- 
portance of  the  fact  that  the  muscles  covering  the  chest  show  a 
reflex  regional  contraction  (spasm)  in  the  presence  of  acute  in- 
flammation in  the  lung  and  that  both  muscles  and  subcutaneous 
tissue  degenerate  if  the  inflammation  assumes  a  chronic  course, 


NECESSITY   OF  STUDYING   CHANGES  IN  SOFT   TISSUES  399 

in  1909.1  These  changes  greatly  modify  the  data  obtained  on 
physical  examination  and  must  be  taken  into  consideration  in 
their  interpretation.  They  also  offer  valuable  signs  of  them- 
selves, which,  when  interpreted  properly,  will  give  valuable  hints 
of  present  or  past  inflammatory  processes  within  the  lung.  The 
soft  tissues  are  also  influenced  by  occupation.  The  muscles  of 
the  right  side  of  the  chest,  particularly  the  pectoralis,  trapezius, 
levator  anguli  scapulse,  and  rhomboidei,  at  times,  show  an  hyper- 
trophy because  of  extra  work;  and;  at  times,  show  atrophy  fol- 
lowing disuse  or  decreased  use  after  such  an  hypertrophy.  A 
general  reduction  in  size  and  lengthening  of  the  muscles  of  the 
shoulder  girdle  permitting  the  shoulder  to  drop,  are  usually 
found  as  a  result  of  righthandedness.  The  changes  in  the  soft 
structures,  whether  physiological  or  pathological  must  be  taken 
into  consideration  in  making  a  physical  examination.  A  point 
of  differential  value  is  that  muscles  degenerated  pathologically 
also  show  atrophy  of  the  subcutaneous  tissue  over  them,  while 
those  lengthened  by  right  or  lefthandedness  and  those  degener- 
ated because  of  disuse  do  not;  also,  the  sternocleidomastoideus 
is  not  apt  to  be  affected  by  either  of  these  conditions,  although 
the  clavicular  portion  lengthens  some  on  the  side  of  greater  use. 
Further,  the  total  density  of  the  lung  tissue  is  greater  if  the 
change  is  due  to  pathological  thickening.  This  is  determined 
by  increased  palpatory  or  percussion  resistance. 

Cause  of  Reflex  Spasm  and  Degeneration  of  Soft  Tissues. — The 
reflex  which  affects  the  soft  tissues  covering  the  bony  thorax  in 
the  presence  of  inflammation  of  the  pulmonary  tissue  is  produced  in 
the  same  manner  as  that  which  affects  the  muscles  of  the  abdo- 
men when  the  abdominal  viscera  are  inflamed.  This  reflex  is  best 
known  in  appendicitis  but  is  present  in  all  inflammatory  condi- 
tions affecting  the  internal  viscera. 

Could  we  but  trace  the  reflex,  I  have  no  doubt  but  that  inflam- 
mation of  every  internal  organ  would  be  expressed  on  some  por- 
tion of  the  surface  of  the  body  by  motor,  sensory  and,  if  it  persists 
for  a  sufficient  time,  by  trophic  changes. 


JA  New  Physical  Sign  Found  in  the  Presence  of  Inflammatory  Conditions  of  the  Lungs 
and  Pleura,  Journal  American  Medical  Association,  March  6,  1909;  and  Muscle  Spasm 
and  Degeneration  in  Intrathoracic  Inflammations  and  Light  Touch  Palpation,  C.  V. 
Mosby  Co.,  St.  Louis,  1912. 


400  DIAGNOSIS   OF  EAELY  PULMONARY   TUBERCULOSIS 

The  path  of  these  reflexes  is  for  the  most  part  through  the 
sympathetica  to  the  cord;  although  there  may  be  other  paths 
such  as  through  the  spinal  accessory  from  the  lung  to  the  sterno- 
cleidomastoideus  and  trapezius  muscles. 

The  reflex  is  segmental  in  character.  This  point  must  be  clear- 
ly understood,  otherwise  the  peculiar  distribution  of  the  reflex 
will  not  be  appreciated.  The  meaning  of  this  will  be  clear  by  re- 
calling that  a  spinal  nerve  is  made  up  of  many  individual  fibers 
which  take  their  origin  from  individual  cells  in  the  cord.  The 
cells  giving  origin  to  the  fibers  which  go  to  make  up  a  nerve 
trunk  may  be  distributed  through  more  than  one  segment  of  the 
cord,  but  individual  cells,  when  irritated,  transmit  their  im- 
pulses only  through  the  fibers  to  which  they  give  origin.  It  is 
not  necessary  that  the  entire  nerve  be  involved  in  the  reflex, 
the  stimulation  may  be  confined  to  a  few  or  it  may  involve  many 
of  its  fibers.  Only  those  fibers  are  involved  which  take  their 
origin  from  cells  which  lie  adjacent  to  and  receive  irritation 
from  other  nerve  cells  which  give  origin  to  fibers,  particularly 
sympathetic  fibers,  which  receive  impulses  from  the  viscera.  This 
is  why  a  portion  of  a  muscle  or  one  of  a  group  may  show  the 
motor  and  trophic  changes  when  the  entire  muscle  or  entire 
group  are  supplied  by  the  same  nerve.  The  path  of  this  reflex 
is  shown  in  Plates  III  and  IV. 

Example  of  the  Effect  of  Spasm  and  Degeneration. — A  con- 
crete example  of  the  way  this  reflex  acts  is  as  follows.  An  in- 
dividual is  suffering  from  an  active  tuberculous  infiltration  of  the 
left  apex.  The  sympathetic  fibers  supplying  that  portion  of  the 
pulmonary  tissue  which  is  inflamed  are  irritated.  They  transmit 
the  impulse  to  the  cells  of  the  cord  which  receives  their  afferent 
impulses.  These  cells  lie  in  the  cervical  portion  of  the  cord.  The 
equilibrium  of  these  cells  is  disturbed.  This  disturbance  is  passed 
on  to  other  nerve  cells  which  lie  adjacent  to  them,  among  which 
are  some  which  give  origin  to  nerve  filaments  which  go  to  make 
up  nerve  trunks,  having  sensory,  trophic,  and  motor  functions. 
The  irritation  of  these  cells  is  passed  on  through  the  filaments 
originating  from  them  to  the  periphery  where  the  sensory, 
trophic,  and  motor  disturbances  are  recorded.    The  nerves  which 


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EXAMPLE  ILLUSTRATING  REFLEX  CHANGES  IN  SOFT  STRUCTURES  401 

take  their  origin  from  the  segments  of  the  cord  which  receive 
the  impulses  from  the  lung,  supply  for  the  most  part  the  surface 
of  the  neck  and  chest  with  sensation,  the  superficial  muscles  of 
respiration,  the  diaphragm,  and  part  of  the  arm  with  motor 
power,  and  the  soft  and  bony  tissues  of  the  thorax  with  trophic 
impulses.  While  the  inflammation  is  acute,  only  sensory  and 
motor  changes  are  apparent,  but  after  it  has  existed  for  a  pro- 
longed time  the  trophic  changes  in  the  soft  tissues  are  also  ap- 
parent. The  two  changes  which  interest  us  most  from  a  diag- 
nostic standpoint  are  the  motor  and  trophic.  In  the  example 
here  given  the  motor  reflex  would  show  in  a  lagging  of  the  left 
side  of  the  chest  owing  to  the  motor  disturbance  of  the  diaphragm 
through  the  left  phrenic  nerve;  and  an  increased  tension  (spasm) 
of  the  muscles  covering  the  left  apex,  particularly  the  sterno- 
cleidomastoideus,  scaleni,  upper  fibers  of  the  pectoralis,  trapezius 
and  probably  the  levator  anguli  scapulas.  The  degree  of  con- 
traction (spasm)  differs  according  to  the  extent  and  activity  of 
the  lesion  because  the  wider  the  area  of  inflammation  the  greater 
the  number  of  sympathetic  fibers  and  the  greater  the  number  of 
cells  in  the  cord  that  are  irritated;  and,  the  more  active  the  in- 
flammation, the  greater  the  degree  of  irritation.  Should  this 
process  go  on  to  a  chronic  state  or  finally  heal,  then  the  trophic 
changes  show  themselves  in  a  wasting  of  the  soft  parts.  The 
skin,  subcutaneous  tissue,  and  muscles  which  are  in  the  area  of 
the  reflex,  degenerate,  and  show  this  change  by  a  thinning  of  the 
skin,  subcutaneous  tissue,  and  muscles  which  are  in  the  area  of 
a  wasting  of  the  muscle  substance.  Should  the  activity  con- 
tinue, or  should  it  again  appear  after  the  process  has  become 
chronic,  then  the  muscles,  degenerated  because  of  the  chronic 
process,  would  also  show  an  attempt  at  contraction  (spasm)  be- 
cause of  the  renewed  inflammation. 

A  second  path  of  reflex  action  to  the  sternocleidomastoideus 
and  trapezius  is  through  the  spinal  accessorius,  the  neurons  of 
which  probably  receive  irritation  from  their  connection  with  sen- 
sory fibers  in  the  vagus.  The  double  path  to  these  muscles  may  ac- 
count for  the  fact  that  the  reflex  spasm  is  strongest  in  these  two 
muscles. 


402  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

No  one  who  desires  to  be  accurate  in  diagnosis  can  fail  to  con- 
sider these  changes  in  the  soft  structures  covering  the  bony- 
thorax;  nor  must  he  fail  to  recognize  that  the  findings  over  a 
rigid  thoracic  cage  are  different  on  palpation,  percussion  and 
auscultation,  from  those  over  one  of  normal  elasticity. 

With  this  introduction,  we  are  now  able  to  take  up  the  discus- 
sion of  the  individual  methods  of  examination  and  the  data  ob- 
tained by  them  with  a  greater  degree  of  accuracy  than  hereto- 
fore. While  many  difficulties  still  present,  particularly  on  the 
part  of  the  examiner,  yet  some  of  the  sources  of  gross  error 
from  the  standpoint  of  the  patient  are  eliminated.  Inspection 
and  palpation  at  once  assume  a  greater  importance  in  diagnosis ; 
and,  percussion  and  auscultation  become  more  accurate. 

INSPECTION. 

Inspection  has  hitherto  not  been  given  its  full  value  in  the 
diagnosis  of  diseases  within  the  chest.  If  one  will  but  look  at 
the  chest,  observing  alterations  in  the  subcutaneous  tissue  and 
muscles  and  then  carefully  observe  the  motion  of  the  chest  wall, 
and  alterations  in  the  contour  of  the  chest  itself,  he  will  have 
important  data  upon  which  to  base  an  opinion  of  the  nature  of 
any  pathological  process,  either  active  or  inactive,  affecting  the 
tissues  within.  Some  of  these  changes  in  old  chronic  affections 
have  been  partly,  but  not  fully,  recognized  for  a  long  time.  The 
changes  in  early  clinical  tuberculosis,  however,  are  not  so  well 
known,  but  are  no  less  valuable  in  the  information  which  they 
furnish. 

In  order  to  be  able  to  detect  the  abnormal,  we  must  have  a 
definite  picture  of  the  normal  thorax  in  mind.  As  has  been  def- 
initely shown  in  Chapter  XIII,  by  the  drawings  from  Mills,  there 
is  no  absolutely  fixed  type  of  chest.  Nevertheless,  we  must  look 
upon  the  flattened  chest  as  an  evidence  of  physical  deterioration, 
and  make  the  normal  rotund  chest  our  ideal.  At  the  same  time,  we 
must  not  call  departures  from  this  type  pathological. 

Dilatation  of  the  Pupil. — Dilatation  of  the  pupil  on  the  af- 
fected side  is  not  an  uncommon  sign  in  pulmonary  tuberculosis. 
This  dilatation  comes  from  stimulation  of  the  sympathetics  which 


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SIGNIFICANCE   OF  LAGGING  403 

take  their  origin  from  the  second  to  fourth  thoracic  segments 
of  the  cord.  It  will  be  recalled  that  the  pupil  is  innervated  by 
both  the  vagus  and  the  sympathetic  divisions  of  the  autonomic 
system.  The  vagus  contracts  and  the  sympathetic  dilates  the 
pupil,  as  described  more  fully  on  page  198.  This  dilatation  is  evi- 
dence of  the  sympathetic  stimulation  overcoming  the  vagus 
tonus.  This  sign  is  inconstant.  It  may  be  present  in  one  in- 
dividual and  not  in  another.  It  may  be  present  at  one  time  and 
absent  at  another.  The  same  is  true  of  symptoms  and  signs  in 
all  organs  where  we  have  this  double  innervation  and  reflex 
stimulation  of  filaments  of  both  systems.  The  same  inconstancy 
is  noted  in  the  heart  action  and  in  the  digestive  disturbances,  as 
described  elsewhere. 

Lagging,  Regional  and  General. — Lagging  is  a  diminished  mo- 
tion of  some  part  of  the  chest  wall.  It  has  usually  been  described 
as  affecting  the  apex  alone,  but  we  find  -it  also  affecting  the  base, 
and,  in  fact,  the  entire  side  as  will  be  appreciated  from  Fig.  60, 
in  which  it  is  shown  schematically  that  the  motion  of  the  entire 
thorax  is  lessened,  and  from  Plate  V,  in  which  the  diaphragm 
reflex  from  the  lung  is  schematically  illustrated. 

Lagging,  as  a  sign  in  early  tuberculosis,  probably  has  at  least 
two  elements  which  enter  into  its  etiology;  a  reflex  motor  dis- 
turbance affecting  the  muscles  of  respiration,  particularly  those 
covering  the  apex  and  the  diaphragm,  and  a  diminished  elastic- 
ity of  the  pulmonary  tissue.  Diminished  elasticity,  however,  can- 
not be  a  very  important  factor  in  the  early  lesions.  Its  most 
marked  action  comes  later  in  the  disease.  It  is  also  at  times  a 
sign  of  previous  or  present  inflammation  of  the  pleura,  the  lag- 
ging being  due  to  inhibited  motion  caused  by  acute  inflamma- 
tion or  adhesions  or  contractions.  It  can  also  be  produced  by 
pericarditis,  pleuritis,  and  inflammations  below  the  diaphragm. 

In  order  to  determine  lagging,  the  chest  should  be  bared  of 
clothing  so  that  the  movements  of  the  entire  thorax  are  visible 
and  unobstructed.  The  movement  of  the  lower  border  of  the 
ribs  is  as  important  as  that  of  the  apices,  consequently  the  waist 
should  not  be  constricted  by  clothing. 

Lagging  may  often  be  detected  more  readily  by  palpation  than 


404  DIAGNOSIS    OF   EARLY   PULMONARY    TUBERCULOSIS 

by  inspection,  although  practice  will  usually  enable  one  to  see 
it.  If  one  is  inspecting  the  apices  for  lagging,  he  can  do  it  either 
by  seating  himself  before  the  patient  and  fixing  his  eyes  so  as 
to  watch  the  motion  of  both  sides  at  once ;  or,  he  may  stand  back 
of  the  seated  patient  and  look  down  over  the  front  of  both 
apices  at  the  same  time.  To  detect  this  sign  at  the  base,  it  is 
best  to  sit  facing  the  patient  who  sits  on  a  stool  a  little  higher 
than  the  examiner.  Lagging  may  be  more  readily  seen  by  plac- 
ing the  hands  on  the  apices  or  bases  as  shown  in  Figs.  83  and 
84.  Whether  this  acts  mainly  by  aiding  vision  or  more  by  add- 
ing the  factor  of  feeling  to  inspection  does  not  seem  wholly 
clear. 

When  inspecting  a  chest  for  lagging  the  patient  should  first 
breathe  normally,  for  forced  breathing  will  often  overcome  the 
lessened  motion.  After  natural  breathing,  then  deep  breathing 
should  be  observed.  Some  observers  claim  that  several  forced 
inspirations  will  tire  the  affected  muscles  and  exaggerate  lag- 
ging; it  seems  to  me,  on  the  contrary,  that  it  more  often  over- 
comes it.  If  lagging  of  one  apex  or  base  is  found  in  suspected 
early  pulmonary  tuberculosis,  it  points  to  the  probable  lesion 
being  on  that  side,  providing  acute  and  chronic  inflammation  of 
the  pleura  be  eliminated. 

If  distinct  signs  of  active  tuberculosis  are  found  in  one  apex 
and  the  motion  of  both  sides  of  the  chest  is  the  same,  it  points 
strongly  to  both  lungs  being  affected,  unless  a  recent  or  old 
pleurisy  is  present  at  the  base  opposite  the  well  defined  lesion. 
If  one  apex  is  the  seat  of  a  fairly  extensive  lesion  which  shows 
slight  or  moderate  activity,  while  the  other  apex  is  the  seat  of 
a  fresh,  though  less  extensive  infiltration,  the  greatest  diminu- 
tion of  motion  is  apt  to  be  on  the  side  of  the  newer  infection,  be- 
cause the  new  reflex  is  more  marked.  When  lagging  is  present 
on  both  sides  it  is  extremely  difficult  to  detect,  but  can  usually 
be  inferred  from  the  changes  observed  in  the  subcutaneous  tis- 
sues and  muscles,  while  percussion  and  auscultation  should  leave 
no  doubt  as  to  its  probable  existence.  Close  observation  and  ex- 
perience will  also  tell  one  about  what  degree  of  motion  to  ex- 
pect in  a  given  chest. 


Fig.  83. — Illustrating  the   method   of  detecting  lagging  at   the   apices. 


Fig.  84. — Illustrating  the  method  of  detecting  lagging  at  the  base.  The  hands  should  be 
laid  gently  on  the  chest  so  as  not  to  interfere  with  the  normal  respiratory  movements. 
Often  a  pressure  no  greater  than  one  or  two  pounds  will  completely  check  the  move- 
ments of  the  ribs. 


DIAGNOSTIC   IMPORTANCE   OF  SOFT   STRUCTURES  405 

The  path  of  the  motor  reflex  causing  lagging  or  diminished 
motion  of  the  chest  wall,  is  from  the  inflamed  area  in  the  lung 
through  the  sympathetic  fibers  and  rami  communicantes  to  the 
cervical  portion  of  the  cord  and  back  through  the  motor  nerve 
filaments  to  the  diaphragm  and  other  respiratory  muscles  sup- 
plied by  cervical  nerves;  also  from  the  pulmonary  endings 'to 
the  filaments  of  the  spinal  accessory  nerve  in  the  sternocleidomas- 
toideus  and  trapezius  as  previously  mentioned. 

State  of  Muscles  and  Subcutaneous  Tissues. — Valuable  informa- 
tion can  be  obtained  in  examining  for  early  tuberculosis  by  care- 
fully observing  the  condition  of  the  muscles  and  subcutaneous 
tissue.  It  is  necessary  in  this  connection  to  emphasize  the  im- 
portance of  examiners  familiarizing  themselves  with  the  normal 
condition  of  the  soft  parts  covering  the  chest  so  that  they  may 
be  able  to  detect  departures  from  the  normal.  The  normal  apex 
should  be  fixed  in  the  examiner's  mind.  In  individuals  of  moder- 
ate or  much  flesh,  the  neck  should  be  fairly  full  and  there  should 
be  no  distinct  groove  either  above  or  below  the  clavicle.  In  pa- 
tients who  are  thin,  on  the  other  hand,  the  clavicle  and  neck 
muscles  will  be  naturally  more  or  less  prominent  and  the  supra- 
spinous fossa  may  be  somewhat  flattened.  In  the  child  these 
parts  on  the  two  sides  are  symmetrical,  but,  as  the  individual 
grows  older,  an  asymmetry  gradually  develops.  When  there  has 
been  a  chronic  inflammation  of  an  apex  followed  by  contraction, 
the  soft  tissues  not  only  atrophy,  but  they  are  drawn  down 
toward  the  apex,  a  condition  which  makes  the  neck  muscles, 
particularly  the  heads  of  the  sternocleidomastoideus,  and  some- 
times other  neck  muscles,  unusually  prominent,  as  shown  in 
Fig.  95,  A  and  B,  page  4.66. 

Occupational  and  Pathological  Changes  in  Soft  Parts  Cover- 
ing Apex. — The  departures  from  the  normal  condition  are  part- 
ly occupational  and  partly  pathological.  The  occupational 
changes  in  the  soft  parts  of  the  neck  and  upper  chest  consist 
in  an  asymmetrical  condition  of  the  muscles  which  control  the 
motions  of  the  arm.  The  muscles  of  the  right  side  are  usually 
developed  to  a  greater  extent  than  those  of  the  left  in  those 
who  use  the  arm  much,  because  of  the  condition  of  right-handed- 


406  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

ness  which  is  almost  universal.  When  these  muscles  cease  to  be 
used,  or  when  they  are  used  less,  or  even  after  much  usage,  a 
retrograde  trophic  change  occurs,  and  the  muscles  become 
smaller,  lengthen,  and  permit  the  shoulder  to  drop,  as  is  evi- 
denced on  the  right  side  in  right-handedness,  and  on  the  left  side 
in  left-handedness. 

The  pathological  changes  are  for  the  most  part  based  on  reflex 
motor  and  -trophic  disturbances  which  result  from  acute  or 
chronic  inflammations  within  the  lung,  the  most  common  cause 
being  tuberculosis.  These  changes  are  sometimes  detected  easily 
and  sometimes  with  more  or  less  difficulty.    They  consist  of: 

1.  An  increased  prominence  of  the  muscles,  particularly  the 
sternocleidomastoideus,  scaleni,  trapezius  and.  levator  anguli 
scapulas,  often  seen  when  active  inflammation  is  present  in  an 
apex  which  has  not  previously  been  involved.  Sometimes  this 
cannot  be  determined  by  inspection,  but  only  by  palpation. 

2.  A  diminution  in  size  of  the  muscles  and  a  wasting  of  the 
subcutaneous  tissue  when  a  lesion  is  present  of  a  chronic  nature 
or  when  one  has  been  present  at  some  previous  time. 

3.  An  increased  prominence  of  some  of  the  bundles  of  the 
muscles  which  appear  somewhat  wasted,  and  a  wasting  of  the 
subcutaneous  tissue  covering  them  when  we  have  an  active 
inflammation  in  an  area  which  had  previously  been  the  seat  of  a 
chronic  process.  This  cannot  always  be  determined  by  inspec- 
tion but  must  sometimes  be  left  to  palpation. 

The  importance  of  recognizing  these  changes  in  the  soft  parts 
is  apparent  when  we  realize  the  frequency  with  which  the  pul- 
monary apices  are  affected  by  tuberculosis  in  adults.  As  pre- 
viously mentioned,  of  400  autopsies  made  by  Hart,  the  apices 
were  affected  in  254  or  63.4  per  cent.  In  the  cases  reported  by 
Naegeli  71.43  per  cent  showed  apical  involvement.  This  means 
that  some  time  in  the  life  of  many  of  the  63.4  per  cent  of  Hart's 
cases  and  71.43  per  cent  of  Naegeli 's  cases  there  were  probably 
reflex  motor  changes  (spasm)  in  the  neck  muscles  which  could 
have  been  recognized  on  inspection  and  palpation  had  they  been 
examined.  It  further  means  that  reflex  trophic  changes  leading 
to  degeneration,  which  were  a  result  of  the  chronic  tuberculous 


IMPORTANCE   OF  SOFT   STRUCTURES  IN   DIAGNOSIS  407 

infection  of  the  underlying  apex,  were  present  in  the  muscles  and 
subcutaneous  tissue  covering  the  apices  in  about  the  same  per- 
centage of  cases.  These  motor  and  trophic  changes  differ  in  de- 
gree but  must  be  taken  into  consideration  in  making  physical 
examinations  of  chests  for  they  of  themselves  alter  the  findings 
often  to  a  very  large  degree ;  and,  in  many  instances  the  trophic 
change  will  call  attention  to  the  presence  of  old  chronic  patho- 
logical processes  within  the  lung  which  are  large  enough  to  altar 
the  resistance  on  palpation  and  the  data  derived  by  percussion 
and  auscultation  far  more  than  the  recent  process  itself. 

It  is  also  desirable  to  determine,  if  possible,  whether  these 
apical  lesions  when  present  are  healed  or  whether  they  are  in 
an  active  state  at  the  time  of  the  examination.  Of  all  methods 
of  physical  examination  this  can  be  best  judged  by  inspection 
and  palpation,  by  noting  the  motion  of  the  chest  wall  and 
whether  or  not  the  muscles  covering  the  apex  have  an  increased 
or  decreased  tone.  By  auscultation  we  can  sometimes  judge 
whether  or  not  activity  is  present ;  but  there  are  no  sounds  heard 
on  auscultation  which  always  mean  activity.  Harsh  breathing, 
rough  breathing,  diminished  breathing,  prolonged  expiration  and 
even  rales  may  be  present  in  arrested  tuberculosis.  If  there  is 
lagging  it  indicates  that  there  is  some  active  interference  with 
the  muscles  of  respiration,  the  sternocleidomastoideus,  scaleni, 
and  particularly  the  diaphragm  on  that  side;  and  if  there  is  an 
increased  tension  of  the  apical  muscles  on  the  same  side,  we  have 
further  evidence  that  there  is  probably  an  active  inflammatory 
process  in  the  corresponding  lung.  If,  along  with  these  motor 
changes  there  is  a  positive  tuberculous  history,  we  are  justified 
in  considering  that  there  is  an  active  lesion  present.  If,  on  the 
other  hand,  we  find  evidence  of  a  lesion  on  palpation,  percussion 
and  auscultation,  but  can  find  no  alteration  in  motion  of  the 
suspected  side  and  no  increased  tension  of  the  apical  muscles; 
but,  on  the  contrary,  a  decreased  tension  and  wasting  of  the  sub- 
cutaneous tissue,  together  with  an  absence  of  symptoms,  we  are 
justified  in  considering  that  we  are  dealing  with  an  old  lesion 
which  is  now  quiescent  or  healed. 

Changes  in  Contour  of  Trapezius  Muscle. — A  significant  sign 


408  DIAGNOSIS    OF   EARLY   PULMONARY    TUBERCULOSIS 

of  an  old  chronic  inflammatory  process  in  the  lung,  evident  on 
inspection  is  a  change  in  the  contour  of  that  portion  of  the 
trapezius  muscle  formed  by  the  junction  of  the  upper  or  occipital 
portion  with  the  middle  portion.  The  normal  trapezius  gradu- 
ally curves  from  the  acromium  to  the  upper  cervical  and  occipital 
portions.  When  the  underlying  apex  has  been  the  seat  of  a 
chronic  inflammatory  process  such  as  tuberculosis,  the  muscle 
degenerates  and  the  subcutaneous  tissue  over  it  becomes  smaller 
than  its  mate  on  the  opposite  side,  as  shown  in  Fig.  85,  A  and  B. 
The  middle  portion  flattens  and  the  junction  between  the  middle 
and  the  superior  fibers  assumes  more  of  an  angular  appearance 
than  normal  and  this  junction  appears  at  a  considerably  lower 
level  than  the  curve  on  the  opposite  side.  The  portion  above  the 
angle  also  appears  smaller  than  its  fellow  on  the  other  side. 
This  condition  is  present  in  those  eases  which  show  a  narrow- 
ing of  the  apical  isthmus  (Kroenig).  It  is  not  a  sign  of  active  or 
clinical  tuberculosis,  but  an  indication  of  a  process  which  has 
been  there  long  enough  to  produce  chronic  changes.  While  this 
is  not  a  sign  of  early  tuberculosis,  yet  its  presence  should  be 
suggestive  in  the  presence  of  symptoms  of  early  disease. 

These  degenerative  changes  in  the  trapezius  are  particularly 
well  shown  in  Fig.  95,  A  and  B,  page  466.  This  patient  suffered 
from  chronic  tuberculosis  affecting  both  lungs.  The  disease  on 
the  right  side,  however,  was  much  more  extensive  and  had  pro- 
duced much  more  destruction  of  tissue  than  that  on  the  left  side. 
The  reflex  trophic  changes  in  the  muscles  and  subcutaneous  tis- 
sue is  well  illustrated  in  the  neck  and  shoulder  girdle  on  both 
sides,  particularly  on  the  right.  The  right  sternocleidomas- 
toideus  is  much  smaller  than  the  left  one.  The  same  is  true  of 
the  pectoralis  trapezius  levator  anguli  scapulas  and  rhomboidei. 
The  wasting  of  these  muscles  has  permitted  the  clavicle,  scapula, 
and  shoulder  as  a  whole  to  drop  down  and  fall  away  from  its 
central  moorings.  It  will  also  be  noticed  that  as  a  result  of  the 
wasting  of  the  soft  tissues  and  their  contraction  the  supra- 
clavicular notches  are  deeper  than  normal  and  the  two  heads  of 
the  sternocleidomastoidei  stand  out  very  prominently.  The 
influence  which  these  muscle  changes  exert  upon  percussion  of 


Fig.    85,4. 


Fig.    8SB. 
Fig.   85. — Illustrating  the  change  in  the  contour  of  the  trapezius  muscle.     A,  anteriorly; 
B,  posteriorly.     This  patient  has  suffered  from  a  chronic  lesion  in  the  right  lung  for  many 
years,    which    has   resulted   in    a   marked    degeneration    of   the    muscles   on    that   side.      The 
right   shoulder   is    not   as   full    as    the   left. 


PALPATION  409 

the  apices  may  be  further  inferred  from  Figs.  96,  A  and  B,  and 
97,  A  and  B,  page  468.  The  latter  are  taken  from  Brecke's  Arti- 
cle in  "Handbuch  der  Tuberkulose. " 

This  sign  is  well  worth  observing  in  early  tuberculosis  now 
that  we  know  so  many  of  our  cases  are  the  result  of  renewed 
activity  in  old  lesions  or  extensions  from  the  other  apex.  It  as- 
sists in  the  proper  interpretation  of  our  findings,  and  becomes 
of  special  value  if  accompanied  on  the  same  side  by  lagging  and 
increased  density  of  the  pulmonary  tissues  as  determined  by 
palpation  and  percussion.  It  may  also  be  due  to  occupational 
changes  but  this  cause  can  be  eliminated  as  mentioned  above. 

Mammary  Gland. — The  mammary  gland  is  often  found  to  be 
smaller  on  the  side  where  there  has  been  an  old  chronic  or  healed 
lesion.  This  is  true  of  non-tuberculous  as  well  as  tuberculous 
processes.  This  shows  as  a  decrease  in  the  subcutaneous  tissue 
and  probably  also  in  a  decrease  in  the  size  of  the  gland  itself. 
Not  only  does  the  gland  appear  smaller  than  the  one  on  the 
other  side  but  it  usually  hangs  lower  on  the  chest  wall,  on  ac- 
count of  the  atrophy  of  the  tissues  which  support  it.  This  con- 
dition is  also  noted  on  the  side  of  the  arm  used  more. 

The  conditions  above  mentioned  are  the  most  important  ones 
to  be  observed  on  inspection  in  examining  for  early  tubercu- 
losis, but  there  are  still  some  others  that  deserve  mention,  such 
as  the  general  appearance  of  the  patient,  the  condition  of  his 
skin,  any  departure  from  the  normal  such  as  enlarged  lymphatic 
glands,  enlarged  thyroid  or  inequality  of  the  pupils. 

PALPATION. 

What  Can  Be  Determined  by  Palpation. — In  a  former  discus- 
sion of  this  subject2  the  writer  said:  "If  we  were  to  confine  our 
examinations  simply  to  the  detection  of  fremitus,  palpation  would 
not  be  of  much  value  in  early  tuberculosis,  but  palpation  in  its 
broader  sense  consists  in  deriving  by  the  sense  of  touch  what- 
ever evidence  we  can  of  the  presence  of  tuberculosis."  Today, 
the  writer  is  able  to  say  that  in  his  own  practice,  palpation,  and 


2Pulmonary  Tuberculosis,  William  Wood  &  Co.,  New  York,   1908. 


410  DIAGNOSIS   OP  EARLY  PULMONARY   TUBERCULOSIS 

particularly  palpation  aided  by  inspection,  has  assumed  an  im- 
portance equal  to,  if  not  greater  than,  percussion  in  the  diagnosis 
and  interpretation  of  intrathoracic  disease. 

By  palpation  we  determine  the  following  data  useful  in  the 
diagnosis  of  early  tuberculosis: 

1.  "Whether  the  muscles  are  normal ;  or  whether  they  show 
an  increased  tone  (spasm)  indicating  either  an  occupational 
hypertrophy  or  a  reflex  hypertonicity  caused  by  an  inflammatory 
process  within  the  thorax;  or,  whether  they  are  degenerated,  in- 
dicating a  retrograde  process  resulting  from  lessened  use,  or  a 
reflex  trophic  disturbance  caused  by  some  intrathoracic  inflam- 
matory condition  which  has  assumed  a  chronic  course. 

2.  Whether  the  skin  is  normal  or  whether  it  shows  regional 
trophic  change. 

3.  Whether  the  subcutaneous  tissue  is  normal  or  whether  it  is 
degenerated.  The  only  common  cause  of  a  regional  degenera- 
tion of  the  subcutaneous  tissue  covering  the  neck  and  chest 
known  to  the  writer  is  that  of  reflex  trophic  disturbance  caused 
by  a  localized  chronic  inflammatory  process  within  the  thorax. 

4.  Increased  resistance  resulting  from  intrapulmonary  in- 
filtrations. In  fact,  palpation  will  give  him  who  is  expert  in 
its  use  nearly  all  information  that  can  be  obtained  on  percussion, 
and  some  that  cannot.  Infiltrations,  cavity,  emphysema,  thick- 
ened pleura,  pleural  effusions,  mediastinal  growths,  the  position 
of  the  heart,  the  lower  border  of  the  lungs,  the  upper  border  of 
the  apices  the  position  of  the  liver,  and  the  outline  of  the 
stomach  under  certain  conditions  can  all  be  determined  by  it. 

5.  The  presence  or  absence  of  lagging  from  which  we  infer 
either  that  the  muscles  of  respiration,  particularly  the  diaphragm, 
are  reflexly  interfered  with  or  are  normal  in  their  action. 

6.  The  presence  or  absence  of  tactile  fremitus. 

7.  The  presence  or  absence  of  enlarged  lymphatic  glands. 
Regional  Spasm  of  Muscles. — By  palpating  the  muscles  of  the 

neck  and  thorax  we  gain  information  additional  to  that  ob- 
tained on  inspection.  The  muscles  which  show  reflex  motor  dis- 
turbance (spasm)  most  markedly  in  early  active  tuberculosis  are 
the  sternocleidomastoideus,  scaleni,  upper  fibers  of  the  pector- 


Fig.  86. — Illustrating  the  method  of  palpating  to  determine  the  condition  of  the  muscles 
and  other  soft  tissues.  The  muscles  should  be  in  the  natural  position  of  repose  and  the 
touch  should  be  light,  scarcely  causing  an  indentation  of  the  tissues. 


REGIONAL  SPASM   OF  MUSCLE  411 

alis,  trapezius,  levator  anguli  scapulas,  and  the  diaphragm,  all 
of  which  are  palpable  except  the  last.  Interference  with  the 
diaphragm  is  inferred  by  lagging  of  the  side,  particularly  the 
base. 

It  is  characteristic  of  this  motor  change  that  it  is  regional  and 
not  general  in  character,  affecting  at  times  only  a  portion  of  a 
muscle  or  a  part  of  a  group  of  muscles. 

Such  signs  and  symptoms  as  dilatation  of  the  pupil,  and  the 
disturbance  in  the  pulse  rate,  and  those  on  the  part  of  the  secre- 
tory and  motor  functions  of  the  gastrointestinal  canal  are  incon- 
stant because  they  are  reflexes  in  which  both  the  vagus  and  sym- 
pathetic divisions  of  the  vegetative  system  are  implicated.  Their 
action  being  antagonistic,  sometimes  vagus  tonus  predominates, 
at  other  times  sympathetic  tonus.  The  reflex  changes  in  the 
muscles  (spasm),  on  the  other  hand,  are  constant,  the  increased 
tone  appearing  when  the  inflammation  hegins  and  continuing 
until  healing  has  taken  place. 

The  normal  muscle  has  a  distinctly  elastic  feel.  The  entire 
muscle  seems  to  have  the  same  general  tone.  When  in  repose 
the  texture  is  firm,  but  not  tense.  When  in  normal  contraction 
the  entire  muscle  takes  on  an  increased  tension.  Whether  in  re- 
pose or  contraction  it  is  elastic. 

When  in  reflex  contraction  (spasm)  some  of  the  muscle  fibers 
are  in  a  state  of  increased  tone,  although  all  may  not  be. 

The  reflex  spasm  is  present  as  an  early  sign  of  intrapulmonary 
inflammation,  hence  is  of  value  as  a  sign  of  early  active  tubercu- 
losis. 

This  contraction  of  the  muscles  may  often  be  determined  by 
inspection,  but  palpation  shows  the  increased  tone  better  and 
gives  more  definite  information.  The  method  of  palpating  is 
shown  in  Fig.  86. 

The  reflex  contraction  may  be  determined  best,  by  light  touch 
palpation.  If  the  finger  tips  are  placed  on  the  muscles  in  a  manner 
similar  to  the  way  they  are  placed  on  the  piano  keys,  and  the 
examiner  will  make  a  rapid  vibratory  motion  pressing  and  re- 
leasing, he  will  feel  a  distinct  resistance  on  the  part  of  the  con- 
tracting fibers  like  that  offered  by  a  bow  string  when  treated  in 


412  DIAGNOSIS    OF   EARLY   PULMONARY    TUBERCULOSIS 

the  same  manner.  This  "bow  string"  feeling  is  quite  character- 
istic. This  increased  tone  may  also  be  determined  by  gently  feel- 
ing the  muscle  or  by  picking  it  up  when  possible  and  rolling  it 
between  the  thumb  and  finger. 

When  this  spasm  is  present,  together  with  a  suspicious  clini- 
cal history,  we  may  be  almost  certain  that  an  active  tuberculous 
lesion  lies  within  the  corresponding  lung.  Figs.  61  to  64,  pages  330 
to  332,  illustrates  schematically  the  principal  neck  muscles  involved 
in  the  reflex  from  the  lung. 

This  spasm  is  sometimes  present  in  muscles  which  have  degen- 
erated because  of  a  previous  inflammatory  process  such  as  when 
we  have  a  renewed  activity  in  an  old  quiescent  focus.  Under  such 
conditions  the  subcutaneous  tissue  is  also  wasted.  The  contrac- 
tion (spasm)  under  these  circumstances  as  a  rule,  is  more  feeble 
than  in  the  undegenerated  muscle,  owing  to  the  atrophy  pres- 
ent, and  the  muscle  has  a  doughy  lifeless  feeling  instead  of  its 
normal  elasticity. 

Increased  tone  (spasm)  of  the  neck  and  chest  muscles  is  con- 
stant in  early  active  tuberculosis.  This  was  first  pointed  out 
by  the  writer  but  has  been  confirmed  by  many  others.  St.  Galecki3 
in  a  recent  contribution  reports  the  finding  of  spasm  in  93  per 
cent  of  early  cases  examined. 

Regional  Atrophy  of  Skin,  Muscles,  and  Subcutaneous  Tissue. — 
A  regional  reflex  change  affecting  the  skin,  muscles  and  subcu- 
taneous tissues  is  present  over  certain  areas  of  the  chest  when 
an  old  chronic  inflammatory  process  has  affected  the  under- 
lying portion  of  the  lung.  This  is  particularly  true  when  a 
chronic  quiescent  or  healed  tuberculous  lesion  is  present.  The 
wasting  is  evident  to  the  eye,  but  it  is  determined  better  by  pal- 
pation. The  parts  which  are  particularly  affected  are  the  same 
muscles  that  have  been  enumerated  as  showing  spasm  and  the 
subcutaneous  tissue  covering  the  same  area. 

Atrophy  of  the  muscles  shows  by  a  wasting  of  their  substance, 
the  belly  of  the  muscles  being  smaller  than  normal.  The  sub- 
stance between  the  bundles  disappears  and  the  muscles  lose  their 
rotundity  and  appear  as  stringy  masses.    The  tips  of  the  fingers 


3Die  Inspektion  und  die  Palpation  des  Thorax  in  der  Diagnose  der  Lungentuberkulose, 
Brauer's  Beitrage  zur  Klinik  der  Tuberkulose,  Bd.  xxx,   1914. 


REGIONAL  ATROPHY  OF  SOFT  PARTS  413 

can  be  more  easily  pressed  between  the  bundles  than  when  nor- 
mal. The  muscles  as  a  whole  show  a  lack  of  elasticity  and  pre- 
sent a  distinctly  doughy  resistance  to  the  finger. 

The  wasting  of  the  subcutaneous  tissue  shows  particularly  in 
the  supraclavicular  and  infraclavicular  notches,  in  the  supra- 
spinous fossas,  and  in  the  interscapular  region.  It  can  best  be 
determined  by  comparing  with  the  normal  side;  or,  where  both 
sides  are  involved,  with  the  subcutaneous  tissue  over  other  parts 
of  the  chest.  By  picking  up  the  skin  and  subcutaneous  tissue 
between  the  thumb  and  fingers,  where  this  is  possible,  it  will  be 
seen  at  once  that  on  the  side  of  the  atrophy  the  tissue  is  much 
thinner  than  on  the  other  side.  This  atrophy  affects  the  skin 
also,  and  in  some  instances,  can  be  readily  determined.  Some- 
times the  line  of  demarcation  between  the  atrophied  and  normal 
subcutaneous  tissue  is  quite  abrupt,  at  other  times  gradual. 

A  point  of  differential  value  in  distinguishing  between  atrophy 
following  muscle  disuse  and  reflex  trophic  disturbance  is  that  in 
the  former  the  subcutaneous  tissue  should  not  be  affected,  while 
in  the  latter  it  is  also  atrophied.  When  this  localized  atrophy 
is  found,  it  should  make  one  think  of  the  possibility  of  some 
chronic  inflammatory  process  particularly  an  old  chronic  tuber- 
culous process,  in  the  corresponding  lung.  If  due  to  a  chronic 
inflammatory  process  this  should  be  determined  by  increased 
resistance  on  palpation  and  percussion. 

Determining-  of  Pulmonary  Infiltrations  by  Palpation. — It  is 
possible  to  learn  to  recognize  differences  in  density  of  tissue  by 
touch  as  well  as  by  percussion.  I  have  found  it  practical  to  use 
palpation  in  the  examination  of  the  chest  where  percussion  is 
generally  used.  Examiners  have  been  gradually  replacing  the 
interpretation  of  the  sound  emitted  on  stroke  by  the  feel  of  re- 
sistance noted  by  the  fingers.  The  utilization  of  touch  to  de- 
termine this  resistance  is  only  carrying  the  point  a  little  further. 
It  has  one  great  advantage.  One  can  palpate  a  definite  small 
area,  but  when  he  percusses,  according  to  the  strength  of  the 
stroke,  he  causes,  as  previously  mentioned,  the  entire  chest,  in 
fact  the  entire  body,  and  even  the  stool  or  bed  on  which  the  pa- 
tient sits  or  lies,  to  be  thrown  into  vibration.    After  he  becomes 


414  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

proficient  the  examiner  will  notice  that  a  different  sensation  is 
conveyed  to  the  palpating  finger  by  the  different  organs  and 
different  pathological  conditions.  Solid  and  hollow  viscera  are 
readily  differentiated.  Infiltrations  in  the  lung  are  easily  dis- 
tinguished from  normal  pulmonary  tissue.  Emphysema,  thick- 
ened pleura,  pleural  effusions,  and  pulmonary  cavities  may  all  be 
detected  by  certain  characteristic  sensations  conveyed  to  the  pal- 
pating finger.  The  thickened  pleura  is  accompanied  by  a  peculiar 
doughy  or  edematous  condition  of  the  overlying  soft  parts  (see 
Chapter  XXV,  Volume  II) . 

Palpation  and  percussion  are  usually  considered  to  be  dis- 
tinctly different  procedures  and  if  we  interpret  the  percussion 
findings  entirely  according  to  sound,  they  are  so;  but,  when  we 
interpret  them  according  to  the  resistance  to  the  finger  it  can 
readily  be  understood  that  the  difference  is  one  of  degree.  Both 
palpation  and  percussion  disturb  the  equilibrium  of  and  set  up 
vibrations  in,  the  tissues  palpated  or  percussed.  These  vibra- 
tions differ  according  to  the  nature  of  and  particularly  accord- 
ing to  the  density  of  the  tissues  through  which  they  pass. 
The  sensations  conveyed  to  the  palpating  finger  or  the  finger 
used  as  a  pleximeter  will  also  differ  according  to  the  density 
of  the  tissues.  Thus  we  learn  to  interpret  a  feeling  of  increased 
resistance  to  the  finger  as  meaning  increased  density  of  the 
tissues.  That  we  can  determine  the  differences  between  sub- 
stances of  different  density  by  touch  can  easily  be  perceived  by 
palpating,  lightly,  pieces  of  metal  or  wood  of  different  thick- 
nesses. The  marked  difference  in  a  piece  of  wood  one-quarter 
of  an  inch  thick  and  another  piece  one  or  two  inches  thick  can 
be  perceived  by  almost  anyone.  Differences  of  lesser  degree, 
while  more  difficult  to  determine,  can  be  easily  made  out  with 
practice. 

For  the  beginner,  in  palpating  chests  for  the  differences  in 
resistance,  I  would  suggest  that  the  resistance  over  the  heart  in 
the  fourth  interspace  to  the  left  of  the  sternum  be  compared 
with  that  over  the  lung  in  the  same  interspace  beyond  the  border 
of  the  heart,  or  that  the  resistance  over  the  liver  be  compared 
with  that  over  the  lung  above  it. 


PALPATING  TOTAL  DENSITY  415 

Patience  and  perseverence  are  required  to  master  palpation 
the  same  as  percussion  and  auscultation ;  but  he  who  will  take  the 
time  and  exercise  the  patience  to  learn  it,  will  be  rewarded  by 
having  at  his  command  a  method  of  examining  which  is  free  from 
that  error  which  comes  from  the  widespread  vibrations  set  up  by 
percussion,  and  one  which  will  often  greatly  aid  him  in  forming 
an  opinion.  While  tactus  eruditus  is  a  factor  in  examining  by 
light  touch  palpation,  practice  and  a  determination  to  learn  it 
are  of  far  greater  importance.  The  practitioner  who  has  stud- 
ied percussion  and  auscultation  for  four  years  while  in  college, 
and  practiced  it  from  one  to  twenty  years  since,  must  not  ex- 
pect to  take  up  palpation  over  night.  It  requires  practice  to  be- 
come proficient  in  its  use. 

When  palpating  a  chest  for  an  early  apical  lesion,  it  is  well 
to  begin  below  and  systematically  feel  the  resistance  over  the 
chest  until  the  apex  is  reached.  It  has  long  been  recognized  that 
there  is  an  increased  resistance  to  the  pleximeter  finger  and  also 
slightly  higher  pitched  note  in  percussing  from  below  upward 
when  the  upper  interspaces  are  reached.  This  also  holds  for  the 
area  immediately  above  the  clavicle.  This  is  most  probably  part- 
ly due  to  the  fact  that  we  are  percussing  over  muscles  near  their 
insertion,  which  condition  offers  more  resistance  in  some  in- 
stances than  when  we  are  percussing  over  the  middle  of  the 
muscle;  partly  due  to  the  fact  that  the  first  interspace  is  nar- 
rower than  the  others  and  partly  to  the  relatively  less  lung  tis- 
sue and  greater  total  thickness  of  the  muscles  as  the  apex  is  ap- 
proached (see  Fig.  65,  page  334).  This  same  condition  is  to  be 
noted  on  palpation,  and  must  not  be  confused  with  an  increased 
resistance  which  might  be  due  to  a  pathological  thickening  of 
the  underlying  pulmonary  tissues.  It  is  extremely  important 
to  bear  these  points  in  mind  so  as  to  avoid  errors  in  diagnosis. 

Palpation  is  found  particularly  valuable  in  the  supraclavicu- 
lar notch.  We  often  notice  a  certain  increased  resistance  (hard- 
ness) over  this  area,  when  the  underlying  apex  is  the  seat  of  a 
tuberculous  process,  which,  if  once  appreciated,  will  not  he  easily 
forgotten  and  which  carries  with  it  considerable  diagnostic  im- 
portance. 

After  several  years'  experience  in  the  use  of  palpation  for 


416  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

the  determination  of  areas  of  different  tissue  density,  I  can  recom- 
mend it  as  being  practical  where  the  difference  is  great  and  as 
being  possible  where  it  is  small.  He  who  attempts  to  take  it  up 
for  the  first  time  may  find  many  discouragements,  but  this  is 
true  of  any  method.  Were  it  taught  to  medical  students  the  dif- 
ficulties would  be  little  if  any  greater  than  those  experienced 
on  percussion.  Comparatively  few  men  can  percuss  and  in- 
terpret their  findings  accurately.  The  advantage  of  having  pal- 
pation and  percussion  to  check  each  other  cannot  be  ignored.  I 
would  especially  urge  those  who  are  giving  special  attention  to 
the  diagnosis  of  diseases  within  the  chest  and  abdomen  to 
practice  palpation,  particularly  light  touch  palpation  with  the 
same  earnestness  that  they  now  practice  percussion. 

Lagging'. — This  sign  was  described  when  discussing  inspection. 
It  can  be  determined  more  readily,  however,  by  palpation  than 
by  inspection.  Sitting  before  the  patient,  who  should  preferably 
sit  on  a  stool  a  little  higher  than  the  examiner,  one  should  place 
his  hands  over  the  lower  ribs  in  the  mid-axillary  lines  while  the 
patient  breathes  quietly  (forced  breathing  often  overcomes  a 
slight  or  moderate  lagging).  If  either  base  lags  it  can  be  readily 
determined.  The  apices  may  be  examined  in  the  same  way,  but 
it  is  preferable  to  examine  them  while  the  examiner  stands  be- 
hind the  patient,  with  his  thumbs  over  the  supraspinous  fossse 
and  his  fingers  extending  down  over  the  clavicles.  The  pres- 
sure exerted  by  the  palpating  hands  must  be  very  gentle  and  be 
the  same  with  both  hands.  Even  a  pressure  of  one  or  two 
pounds  may  be  sufficient  to  overcome  the  motion  of  the  chest 
wall. 

Lagging  is  not  difficult  to  detect  when  one  side  only  is  in- 
volved; but  when  bilateral  involvement  is  present  there  is  some 
difficulty  because  the  movements  may  be  about  equal  on  the  two 
sides.  When  there  is  a  double  lesion,  however,  it  is  usually  more 
marked  on  one  side  than  the  other.  It  can  plainly  be  seen  that 
there  should  be  a  lagging  on  the  side  of  the  pronounced  involve- 
ment, so  a  limited  motion  on  the  other  is  presumptive  evidence 
that  a  lesion  exists  in  that  lung  also.  It  must  not  be  forgotten 
that  the  left  base  naturally  shows  a  slightly  lessened  motion  when 


PERCUSSION  417 

compared  with  the  right,  probably  because  the  right  side  of  the 
diaphragm,  has  the  liver  for  a  fulcrum  which  acts  in  forcing  the 
right  lower  part  of  the  chest  wall  out. 

Tactile  Fremitus. — Tactile  fremitus  is  the  vibratory  sensation 
conveyed  to  the  palpating  finger  or  hand  when  laid  upon  the 
chest  while  the  patient  is  speaking.  Certain  definite  words,  like 
"one,"  "two,"  "three,"  or  "ninety-nine,"  are  used  because  they 
produce  a  maximum  vibratory  effect. 

Fremitus  differs  according  to  the  character  of  the  voice  and 
the  character  and  thickness  of  the  tissues  through  which  the 
vibrations  must  pass.  It  is  naturally  more  marked  over  the  right 
apex.  The  reason  for  this  has  probably  been  correctly  assigned 
by  Fetterolf  to  the  fact  that  the  trachea  lies  in  direct  contact 
with  the  pulmonary  tissue  on  the  right  while  the  large  vessels  lie 
beween  the  trachea  and  pulmonary  tissue  on  the  left. 

Any  pathological  condition  which  produces  a  thickening  of 
the  pulmonary  tissue  will  cause  an  increased  fremitus;  there- 
fore this  should  be  of  value  in  the  diagnosis  of  tuberculosis. 
There  are  so  many  signs  of  greater  value,  however,  that  this  is 
rarely  relied  on  to  any  extent.  Vocal  fremitus,  usually  spoken 
of  as  voice  transmission,  as  determined  by  the  stethoscope  is  more 
reliable  than  that  determined  by  palpation. 

Enlarged  Glands. — The  determination  of  enlarged  glands,  par- 
ticularly those  of  the  cervical  group  at  times  has  some  bearing 
on  the  pulmonary  involvement. 

PERCUSSION. 

Light  or  Heavy  Percussion. — During  recent  years  methods  of 
examination  have  taken  on  many  improvements.  In  percus- 
sion, as  previously  stated,  there  is  a  growing  tendency  toward  a 
lighter  stroke  and  greater  attention  to  the  sensation  of  resistance 
conveyed  to  the  finger  in  comparison  with  the  sound  produced 
by  the  stroke. 

It  was  believed  until  recently  that  it  was  necessary  to  employ 
a  heavy  stroke  in  order  to  percuss  deep  lying  organs  or  portions 
of  organs,  but  we  now  know  this  is  erroneous.    This  idea  is  illus- 


418  DIAGNOSIS   OF   EARLY   PULMONARY    TUBERCULOSIS 

trated  in  Fig.  87  taken  from  Sahli's  work  on  Physical  Diag- 
nosis. Deep  infiltrations  in  the  lung,  the  deep  borders  of  the 
heart  and  liver,  and  mediastinal  growths  can  be  determined  by  light 
touch  palpation.  The  lighter  the  percussion  stroke  the  better,  be- 
cause a  heavy  stroke  causes  widespread  vibrations  of  all  the  neigh- 
boring tissues  as  well  as  the  bony  thorax;  and  causes  increased  dif- 
ficulty in  interpretation.  A  stroke  so  light  that  it  is  scarcely 
audible  can  be  perceived  through  the  entire  thickness  of  the 
chest,  as  can  readily  be  determined  by  placing  the  palm  of  the 
hand  on  the  front  of  the  chest  wall  while  a  light  percussion  stroke 
is  applied  to  the  back. 

Careful  diagnosticians  have  learned  that  there  are  many  sources 
of  error  in  the  interpretation  of  the  percussion  note  and  are  more 
and  more  depending  on  the  resistance  noted  by  the  finger.    This 


j?ig.  87. — The  acoustic  sphere  of  action  of  the  blow  in  deep  percussion.  Origin  of  the 
deep  dullness.  An  illustration  purporting  to  show  the  supposed  necessity  for  heavy  per- 
cussion, a-b,  cross-section  through  the  anterior  wall  of  the  thorax;  c-d,  cross-section 
through  the  heart;  elliptical  shadow  areas  representing  the  sphere  of  vibration  caused 
by  percussion;  e-d,  the  shadow  area,  is  wholly  within  the  lung  and  does  not  reach  the 
heart;  /,  is  partly  in  lung  tissue  and  partly  in  the  heart,  consequently  it  gives  informa- 
tion. (Sahli.)  As  explained  throughout  these  pages,  this  conception  is  erroneous.  The 
deep  borders  of  the  heart  may  be  outlined  by  a  touch  or  by  a  stroke  so  light  that  it  is 
barely  audible. 

is  of  special  importance  in  all  chest  conditions.  There  are  many 
methods  of  percussion  but  there  are  none  superior  to  finger-fin- 
ger percussion  if  the  examiner  is  skilled  in  its  use;  for  it  has 
the  advantage  of  delivering  the  stroke  and  receiving  the  impres- 
sion of  the  stroke  by  instruments  in  which  the  sense  of  touch 
may  be  keenly  cultivated.  The  best  percussion,  however,  is  that 
done  in  the  manner  which  the  particular  examiner  knows  best 
and  interprets  most  accurately. 

It  is  very  important  in  comparing  the  findings  on  percussion 
over  different  areas  of  the  chest,  to  percuss  under  as  nearly  the 


Fig.    88A. 


Fig.    88B. 

pjg,  g8. — Illustrating  a  common  error  in  percussing  the  apices.  A,  proper  position, 
showing  percussion  of  the  apices  while  the  patient's  head  is  erect  and  tension  removed 
from  the  sternocleidomastoideus  and  other  neck  muscles.  B,  wrong  position,  percussing 
same  when  the  head  is  turned  and  bent  over  toward  the  opposite  side,  thus  putting  the 
sternocleidomastoideus  and  other  muscles  on  tension,  thereby  raising  the  pitch  of  the 
percussion  note  and  increasing  the   resistance  to  the  percussion  finger. 


PERCUSSION 


419 


same  conditions  as  possible.  The  arms  should  be  in  the  same 
position.  All  muscles  should  be  relaxed.  Tlie  head  should  be 
in  the  median  position.  A  very  common  error  is  to  percuss  one 
supraclavicular  notch  with  the  head  erect  and  face  forward  and 
the  other  with  the  face  turned  to  the  opposite  side ;  or  trying 
to  compare  findings  derived  while  the  head  is  turned  to  one 
side,  as  shown  in  Fig.  88,  A  and  B.  Turning  the  face  to  the  op- 
posite side  throws  the  muscles  of  the  neck  on  a  stretch  which 
results  in  a  higher  pitched  note  and  greater  resistance  to  the 


M.    scalenus 
posterior 

M.   trapezius 


M.    sternocleido- 
mastoideus 


M.  scalenus  medius 


M.  scalenus  anterior 


Fig.   89. — Important  muscles  which  affect  percussion   of  apices  anteriorly,   shown 
schematically.      (Geihartz.) 

finger,  thus  giving  wrong  information.  The  important  muscles 
which  affect  apical  percussion  anteriorly  are  shown  schematically 
in  Fig.  89. 

The  percussion  note  differs  in  different  chests.  Each  must  be 
considered  by  itself,  consequently  there  is  no  note  or  tone  that 
can  be  interpreted  to  mean  a  definite  pathological  condition.  In- 
creased or  decreased  resistance  to  the  finger,  however,  always 
means  relatively  greater  or  lesser  density  of  tissue. 


420  DIAGNOSIS   OF  EARLY   PULMONARY   TUBERCULOSIS 

Percussion  Changes  in  Early  Clinical  Tuberculosis. — The  per- 
cussion findings  in  early  tuberculosis  vary  greatly  in  different  in- 
dividuals, and  are  modified  by  the  nature  of  the  infiltration  itself ; 
by  the  condition  of  the  lung  tissue  and  surrounding  structures ;  by 
the  elasticity  of  the  bony  thorax;  by  the  amount  of  soft  tissue 
covering  the  bony  thorax  and  by  the  conditio-n  of  the  muscles 
and  subcutaneous  tissue.  One  will  soon  learn  to  gauge  the  allowance 
to  be  made  on  account  of  the  soft  structures. 

If  the  infiltration  is  dense  this  should  give  a  high  pitch  to  the 
note  emitted  on  percussion  and  a  marked  resistance  to  the  plexi- 
meter  finger.  If  it  is  scattered  it  might  cause  so  slight  an  eleva- 
tion of  the  pitch  as  not  to  be  noticeable ;  it  might  take  on  a  tym- 
panitic quality,  or  it  might  cause  so  little  increased  density  of  the 
tissues  that  it  would  not  be  perceived  by  the  palpating  finger. 
This  is  what  we  would  find  if  we  were  percussing  a  lung  con- 
taining a  scattered  infection,  without  regarding  its  coverings. 
But  we  find  it  necessary  to  take  the  bony  frame  work  and  soft 
tissues  covering  the  parts  into  consideration.  This  increases  our 
difficulties  of  interpretation  and  throws  greater  responsibility 
upon  the  examiner. 

Recalling  the  statistics  of  Hart  and  Naegeli  before  mentioned, 
which  show  that  between  60  and  70  per  cent  of  adults  have  tu- 
berculous deposits  of  greater  or  lesser  dimensions  in  their  lungs, 
usually  the  apices,  we  can  see  that  we  are  not  always  percussing 
fresh  infiltrations  of  normal  lung  tissue.  Recalling  also  that  these 
old  chronic  processes  cause  trophic  disturbances  in  the  soft  struc- 
tures covering  the  apices  (muscles  and  subcutaneous  tissue)  then 
we  have  an  idea  of  the  problem  before  us.  The  greater  the 
amount  of  solid  tissue  covering  the  portion  of  the  lungs  through 
which  we  percuss  and  the  greater  the  density  of  such  tissue, 
the  higher  the  pitch  of  the  note  and  the  greater  the  resistance 
to  the  finger.  Therefore,  large  muscles  and  muscles  in  contrac- 
tion and  a  large  amount  of  firm  subcutaneous  tissue  cause  higher 
pitch  and  increased  finger  resistance  as  compared  with  the  same 
muscle  in  relaxation,  and  the  same  subcutaneous  tissue  when 
atrophied. 

Bearing  these  factors  in  mind  we  find  the  following  different 


SOFT  STRUCTURES  AFFECTING  PERCUSSION  421 

conditions  on  percussion  of  the  apices  when  tuberculous  involve- 
ment is  present. 

1.  A  primary  active  involvement  of  one  apex.  This  condi- 
tion presents  normal  subcutaneous  tissue  over  both  apices,  nor- 
mal muscles  over  the  healthy  apex  and  muscles  showing  in- 
creased tone  (spasm)  over  the  diseased  apex.  The  amount  of 
spasm  present  depends  on  the  extent  and  degree  of  activity  in 
the  lesion.    Of  course,  occupational  influences  must  be  considered. 

In  this  instance  it  is  necessary  to  compare  the  percussion  of  a 
normal  lung  through  normal  tissue,  with  an  infiltrated  lung 
through  muscles  whose  tone  is  increased  by  being  thrown  into 
reflex  spasm.  The  result  is  that  the  pitch  of  the  percussion  note 
and  the  resistance  to  the  finger  are  increased  by  both  factors  over 
the  diseased  apex,  and  should  be  readily  detected.  Often,  if  not 
generally,  the  changes  wrought  in  the  percussion  phenomena  by 
the  increased  tone  of  the  muscles  is  greater  in  early  clinical  tu- 
berculosis than  that  produced  by  the  pathological  thickening 
in  the  pulmonary  tissue. 

2.  An  old  quiescent  or  healed  lesion  in  one  apex.  According 
to  the  extent  of  the  lesion  we  find  degeneration  of  the  apical 
muscles,  particularly  the  sternocleidomastoideus  and  trapezius; 
probably  also  of  the  upper  fibers  of  the  pectoralis,  and  possibly 
the  scaleni  and  levator  anguli  scapulas.  The  subcutaneous  tissue 
over  this  area  is  also  atrophied.  The  points  where  this  wasting 
can  be  best  detected  are  in  the  supraclavicular  and  infraclavicu- 
lar regions,  and  with  less  ease  in  the  supraspinous  fossa.  This 
condition  is  illustrated  schematically  by  Fig.  90,  page  422. 

In  this  instance  it  is  necessary  to  compare  percussion  findings 
through  atrophied  muscles  and  subcutaneous  tissue  over  one 
apex  with  normal  elastic  muscles  and  normal  subcutaneous  tis- 
sue over  the  other.  If  the  pulmonary  tissue  at  the  two  apices 
could  be  the  same  under  these  conditions,  the  percussion  note 
would  be  higher  and  the  resistance  to  the  finger  greater  on  the 
side  of  the  normal  soft  parts  because  of  the  greater  thickness  of 
the  tissues  on  that  side.  This  same  holds  true  when  one  apex 
is  the  seat  of  a  tuberculous  infiltration  unless  there  is  a  sufficient 
amount  of  pathological  thickening  present  in  the  lung  to  more 


422 


DIAGNOSIS   OF   EARLY  PULMONARY   TUBERCULOSIS 


than  overcome  the  decrease  in  soft  tissues  which  is  due  to  wasting 
of  the  muscles  and  subcutaneous  tissue.  If  the  lesion  in  this  in- 
tance  has  thoroughly  healed  there  should  be  no  clinical  symp- 
toms present,  the  muscles  should  show  no  spasm  barring  pleural 
adhesions,  the  motion  of  the  diaphragm  should  show  no  marked 
diminution  and  the  percussion  over  the  remaining  portion  of  the 
lung  should  be  practically  normal.  Theoretically,  at  least,  there 
is  a  slight  change  in  the  percussion  note  when  lagging  is  pres- 
ent because  the  lung  contains  relatively  less  air. 


Fig.  90. — Illustrating  schematically  the  degenerative  effects  upon  soft  tissues  produced 
reflexly  by  an  old  chronic  inflammation  in  the  apex  of  the  lung.  It  will  be  noticed  that 
on  the  side  where  heavy  shading  indicates  a  lesion  in  the  apex,  the  subcutaneous  tissue 
and  muscle  mass  is  much  smaller  than  on  the  other.  This  materially  influences  the  per- 
cussion note,  and  must  be  considered  in  interpreting  findings,  on  palpation,  percussion, 
and  auscultation. 


Percussion  over  the  affected  apex  under  these  circumstances 
may  show  an  increased  resistance  to  the  finger  and  a  higher 
pitched  note  than  the  normal  apex,  or  one  equal  in  intensity  or 
one  less  in  intensity  according  to  the  amount  of  thickening  pres- 
ent in  the  lung  and  the  amount  of  wasting  which  has  taken  place 


INFLUENCE   OP   SOFT   TISSUES   ON   PERCUSSION  423 

in  the  muscles  and  subcutaneous  tissues.  The  greatest  changes 
occur  in  patients  with  heavy  muscles  and  thick  subcutaneous  tis- 
sue. Not  infrequently  is  the  higher  pitch  and  greater  resistance 
found  on  the  normal  side. 

3.  An  old  quiescent  focus  in  one  apex  which  has  taken  upon 
itself  renewed  activity.  Here  we  have  the  same  degeneration  of 
the  muscles  and  subcutaneous  tissue  as  mentioned  above.  Aside 
from  this  there  is  a  renewed  inflammation  in  the  lung  which 
causes  the  same  muscles  to  contract  renexly  (muscle  spasm). 

On  percussion  we  are  comparing  the  results  obtained  by  per- 
cussing an  infiltration  through  atrophied  subcutaneous  tissue  and 
atrophied  muscles  which  are  again  thrown  into  a  state  of  mild 
contraction  with  those  obtained  by  percussing  a  normal  apex 
through  normal  muscles  and  normal  subcutaneous  tissue.  It  is 
impossible  to  tell  by  percussion  what  part  of  the  changes  found 
over  the  pathological  apex  is  caused  by  the  old  lesion  and  what 
part  is  due  to  the  new.  Activity  should  be  suspected  in  all  such 
cases  if  lagging  is  present  and  the  muscles  should  seem  somewhat 
tense,  especially  if  a  positive  clinical  history  is  present.  The 
percussion  note,  however,  will  be,  at  least  theoretically,  a  little 
higher  in  pitch  and  the  resistance  to  the  finger  will  be  some- 
what greater  for  the  amount  of  pathological  thickening  present, 
than  is  found  over  a  healed  lesion  of  equal  extent  because  of 
the  added  factor  of  the  slight  increase  in  muscle  tone.  We  meet 
the  same  conditions  here,  however,  as  we  did  above,  and  unless 
the  amount  of  infiltration  in  the  pulmonary  tissue,  plus  the 
added  factor  of  the  contraction  of  the  muscles  is  more  than  suf- 
ficient to  compensate  for  the  loss  of  subcutaneous  tissue  and 
wasting  of  the  muscles,  the  percussion  note  and  the  resistance  to 
the  finger  will  be  the  greater  over  the  healthy  apex.  This  con- 
dition is  often  met  with  and  very  frequently  misinterpreted. 
Here  also,  percussion  findings  may  be  greater,  less,  or  equal  to 
those  of  the  healthy  side  according  to  the  size  of  the  infiltra- 
tion and  the  amount  of  degeneration  which  has  taken  place  in 
the  muscles  and  subcutaneous  tissues. 

4.  An  old  healed  focus  in  one  apex  and  a  new  involvement  of 
the  other  apex.     This  presents  a  puzzling  condition  on  percus- 


424  DIAGNOSIS   OF  EARLY   PULMONARY   TUBERCULOSIS 

sion.  At  one  apex  we  have  the  atrophied  muscles  and  subcu- 
taneous tissue  tending  to  decrease  the  percussion  findings  and  a 
thickening  of  the  pulmonary  tissue  due  to  the  old  quiescent  focus, 
tending  to  increase  the  percussion  findings;  while  at  the  other 
apex  we  have  an  increased  tone  in  the  muscles  (spasm)  and  the 
new  infiltration  both  tending  to  increase  percussion  findings. 

If  the  findings  on  percussion  of  the  two  apices  approach  each 
other,  the  examiner  may  fall  into  the  error  of  believing  that  both 
are  normal.  If  the  old  lesion  is  of  sufficient  magnitude  to  give  a 
higher  pitched  note  and  greater  resistance  to  the  finger  on  per- 
cussion than  those  obtained  over  the  apex  which  is  the  seat  of 
the  new  lesion,  the  new  lesion  is  apt  to  be  overlooked.  If  the 
findings  on  the  side  of  the  new  lesion  are  markedly  greater  than 
over  the  apex  with  the  old  lesion,  then  the  lesion  is  apt  to  be  as- 
signed to  the  side  of  the  new  lesion  and  the  old  one  be  over- 
looked. 

Lagging  of  the  side  of  the  new  involvement  and  spasm  of  the 
neck  muscles  should  aid  in  the  proper  interpretation  of  the  find- 
ings. 

5.  An  old  quiescent  focus  which  has  again  become  the  seat  of 
activity  in  one  apex  and  a  new  active  process  in  the  other  apex. 
This  condition  presents  wasting  of  the  muscles  and  subcutaneous 
tissue,  with  increased  tone  of  the  degenerated  muscle  (spasm) 
caused  reflexly  by  the  renewed  activity,  over  the  apex  which  is 
the  seat  of  the  old  lesion;  and  an  increased  tone  of  the  muscles 
(spasm)  which  may  be  slight  or  very  marked,  according  to  the 
size  and  activity  of  the  lesion,  over  the  apex  of  more  recent 
involvement. 

The  percussion  findings  under  these  circumstances  will  de- 
pend very  much  upon  the  degree  of  infiltration  present  in  the 
two  lungs.  If  the  findings  over  the  two  apices  approach  each 
other  they  may  be  erroneously  considered  as  negative.  If  they 
greatly  preponderate  on  one  side  the  lesion  may  be  assigned  to 
that  side  alone. 

In  this  class  of  cases  the  spasm  of  the  muscles  and  lagging 
when  considered  together  should  help  greatly.  Both  sides  should 
show  lagging  because  both  apices  are  the  seat  of  active  disease. 


INTRATHORACIC    CONDITIONS   AND   PERCUSSION   NOTE  425 

It  should  be  greater  on  the  side  of  the  new  lesion  unless  the  ex- 
tent and  activity  is  markedly  greater  on  the  other  side.  If  the 
other  side  be  the  seat  of  a  recent  pleurisy  or  of  pleuritic  adhe- 
sions; or  if  both  sides  lag,  the  motion  being  about  equal,  then  the 
condition  of  the  neck  muscles  will  give  much  information.  A 
marked  spasm  of  the  neck  muscles  on  the  side  of  the  new  involve- 
ment with  lagging  equal  or  nearly  equal  on  the  two  sides,  in- 
dicates that  activity  and  probably  greater  activity  is  present  to 
cause  the  marked  lagging  on  that  side. 

Percussion  under  these  conditions  should  give  definite  findings, 
both  sides  showing  plainly  the  departure  from  the  normal.  How 
much  the  increased  pitch  and  increased  resistance  to  the  finger  is 
due  to  the  increased  resistance  offered  by  the  contracted  muscles, 
and  how  much  to  the  infiltration  per  se,  is  difficult  to  determine; 
but,  however  this  is,  this  type  of  involvement  should  be  most 
readily  made  out  on  percussion. 

Percussion  does  not  tell  that  the  lesion  is  active,  but  the  spasm 
of  the  muscles,  the  changes  on  auscultation,  and  the  positive 
clinical  history  should  be  present  and  aid  in  forming  an  opinion. 

Conditions  Within  the  Chest  Which  Alter  the  Percussion  Note. — 
All  pathological  conditions  in  the  lung,  mediastinum,  or  pleural 
cavity  alter  the  percussion  findings.  Of  these,  aside  from  pre- 
vious tuberculous  infections  which  have  been  discussed,  fibrosis, 
resulting  from  an  old  pneumonia,  emphysema,  enlarged  media- 
stinal glands  and  the  results  of  pleurisy  or  empyema,  are  of 
special  importance. 

Where  one  lung  has  been  seriously  crippled  by  an  extensive 
fibrosis,  a  pleurisy,  empyema,  or  a  tuberculous  infiltration,  the 
other  lung  takes  upon  itself  a  compensatory  emphysema.  The 
signs  of  a  new  tuberculous  infection  on  this  side  are  easily  over- 
looked because  the  lung  is  comparatively  less  dense  than  nor- 
mal. A  percussion  note  over  this  emphysematous  lung,  plus  the 
infiltration,  may  still  be  lower  in  pitch  than  that  produced  by 
normal  lung  tissue,  and  the  resistance  to  the  finger  may  be  less 
than  normal.  Especial  difficulty  often  presents  in  diagnosing  a 
new  infection  when  one  lung  has  been  the  seat  of  a  severe  tuber- 
culous involvement  and  the  other  after  taking  upon  itself  a  high 


426  DIAGNOSIS   OF   EARLY   PULMONARY    TUBERCULOSIS 

degree  of  compensatory  emphysema,  has  become  the  seat  of  an 
infiltration. 

Percussion  Gives  No  Evidence  of  Activity. — From  what  pre- 
cedes, it  can  be  seen  that  percussion  per  se  gives  no  information 
whatsoever  that  will  enable  us  to  differentiate  between  active, 
and  quiescent  or  healed  lesions ;  but  should  be  considered  in  con- 
nection with  the  clinical  history,  state  of  the  muscles,  subcu- 
taneous tissue,  the  action  of  the  diaphragm  and  the  tuberculin 
test.  With  our  present  knowledge  of  the  frequency  of  quiescent 
and  healed  lesions  in  the  lung,  it  is  not  sufficient  to  find  evidence 
of  pathological  thickening  on  percussion.  A  presumptive  diag- 
nosis, even,  cannot  be  given  on  this  alone,  for  it  might  be  due  to 
an  entirely  harmless  process  which  has  fully  spent  its  activity. 

Kroenig's  Apical  Percussion. — This  consists  in  mapping  out 
the  width  of  pulmonary  resonance  over  the  apex.  Too  much  re- 
liance has  been  placed  on  this  in  early  diagnosis,  as  can  be 
readily  understood  by  recalling  the  pathological  data  which  have 
been  previously  given.  A  narrowing  of  the  area  of  apical  reso- 
nance indicates  only  the  presence  of  a  pathological  condition  with- 
in that  apex  (usually  tuberculosis)  but  does  not  indicate  that 
it  is  the  cause  of  clinical  symptoms  at  the  time.  This  must  be 
determined  by  other  methods  such  as  the  clinical  history  and  the 
state  of  the  muscles,  the  movement  of  the  diaphragm,  the  aus- 
cultatory signs  and  the  tuberculin  test.  Of  itself,  however,  it 
gives  very  suggestive  evidence. 

AUSCULTATION. 

This  subject  is  one  of  the  most  important  in  connection  with 
the  early  diagnosis  of  tuberculosis.  It  is  likewise  the  object  of 
more  abuse  than  any  other  method.  Comparatively  few  men 
have  had  sufficient  training  or  experience  to  enable  them  to  make 
a  diagnosis  of  incipient  tuberculosis  from  the  data  derived  by 
auscultation  alone,  before  the  advent  of  gross  signs.  "With  the 
more  intensive  teaching  of  medical  students  today  this  criticism 
should  not  hold  with  the  newer  generation  of  physicians.  Un- 
fortunately, the  difficulties  surrounding  auscultation  are  not 
sufficiently  recognized,  and  many  men  who  examine  chests,  find- 


AUSCULTATION  427 

ing  nothing  which  they  recognize  as  abnormal,  give  an  opinion 
accordingly  in  the  face  of  definite  symptoms  of  active  disease. 
This  often  proves  disastrous  to  the  patient  for  it  affords  false 
security. 

The  physician  who  is  not  expert  in  examining  chests  must 
not  make  his  diagnosis  depend  upon  auscultation  or  upon  any 
other  single  method  of  examination.  If  he  does  he  ivill  diagnose 
only  late  tuberculosis.  He  must  rely  more  and  more  on  clinical 
history  and  the  tuberculin  tests  and  from  them  make  a  diagnosis 
of  probable  pulmonary  tuberculosis ;  but  this  should  assure  safety 
to  the  patient  for  he  can  then  be  told  of  the  suspected  condition 
and  be  put  on  proper  treatment;  or  an  expert  can  be  called  to 
complete  the  diagnosis. 

Stethoscope. — There  is  a  great  difference  in  the  various  stetho- 
scopes used  by  different  examiners.  All  are  not  equally  good. 
Some  exaggerate  sounds  more  than  others.  Those  having  much 
metal  about  them,  particularly  in  the  conducting  portions,  have  a 
roar  about  them  that  is  not  present  when  the  conducting  tubes 
are  of  soft  rubber.  The  small  bell  with  soft  rubber  conducting 
tubes,  transmits  the  sounds  with  the  least  change  and  has  many 
advantages.  The  best  stethoscope,  however,  is  the  one  the  in- 
dividual examiner  knows  how  to  interpret  best.  The  intensity 
of  sound  depends  somewhat  on  the  pressure  applied  to  the  stetho- 
scope. The  more  lightly  the  bell  of  the  instrument  is  applied  to 
the  chest  the  more  intense  the  sound.  Experimenting  with  the 
Bock  stethoscope  which  has  a  diaphragm  through  which  the 
sound  passes,  and  which  may  be  closed  by  the  diaphragm,  I  found 
that  there  was  25  per  cent  greater  intensity  in  sound  when  the 
bell  was  applied  lightly  than  when  firm  pressure  was  made. 

No  clothing  should  intervene  between  the  stethoscope  and  the 
skin.  When  the  chest  is  covered  with  hair  great  uncertainty  ex- 
ists in  the  study  of  the  respiratory  murmur  and  in  the  interpreta- 
tion of  any  adventitious  sounds  that  may  be  present.  Different 
writers  have  recommended  that  the  hairs  be  wet  with  water  or 
greased  with  vaseline  in  order  to  overcome  this  interference.  A 
much  better  procedure  is  to  clip  the  chest.  For  several  years  I 
have  included  a  pair  of  barber's  clippers  in  my  examining  out- 


428  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

fit.  It  has  greatly  facilitated  my  work  and  added  to  the  ease 
and  accuracy  of  the  examination. 

Method  of  Breathing  During  Auscultation. — The  manner  in 
which  the  patient  breathes  during  auscultation  is  of  great  im- 
portance. Inasmuch  as  the  examiner  should  listen  during  both 
inspiration  and  expiration,  it  is  well  to  have  the  patient  breathe  a 
little  deeper  and  a  little  faster  than  normal.  Forced  respiration, 
however,  should  not  be  employed  at  first,  for  this  disturbs  the 
rhythm  of  the  respiratory  note.  Deep  breathing  causes  a  com- 
parative prolongation  of  the  expiratory  note.  This  prolonged  ex- 
piratory note  is  often  not  heard  because  the  examiner  fails  to 
listen  sufficiently  long  and  sufficiently  intently.  The  breath 
sounds  should  be  freed  from  adventitious  sounds  produced  in  the 
nose  or  larynx.  Sometimes  it  is  necessary  to  have  the  patient 
breathe  with  open  mouth  to  overcome  the  sounds  caused  by  a 
nasal  obstruction. 

The  patient  should  be  examined  while  breathing  quietly  as 
mentioned  above,  then  during  deep  inspiration,  and  finally  after 
a  short  cough  followed  by  inspiration.  This  is  particularly  neces- 
sary in  examining  for  rales.  Often  a  deep  inspiration  will  show 
rales  where  a  shallow  inspiration  will  not ;  and  a  cough  followed 
by  inspiration  will  show  them,  when  both  shallow  and  deep 
inspiration  fail.  No  physical  examination  for  tuberculosis  and 
particularly  for  early  clinical  tuberculosis  should  be  considered 
complete  without  auscultating  during  deep  breathing,  and  cough 
followed  by  deep  inspiration. 

Abdominal  breathers  are  often  difficult  to  examine  because  of 
the  weakness  of  the  respiratory  note  over  the  apices.  This  can 
be  partially  overcome  by  instructing  them  how  to  breathe  with 
the  upper  portion  of  the  chest.  In  this  connection  it  should  be 
emphasized  that  the  ventilation  of  the  lungs  is  increased  when  the 
patient  sits  or  stands  and  decreased  when  he  lies  down,  conse- 
quently sitting  or  standing  brings  out  the  changes  on  percussion 
more  plainly. 

The  Effect  of  Muscles  on  the  Respiratory  Note. — Contrary  to 
the  usual  advice  about  the  position  of  the  arms  during  ausculta- 
tion, I  prefer  always  to  listen  through  a  muscle  which  is  relaxed 


MUSCLE  ELEMENT   HEARD   IN  RESPIRATORY  NOTE  429 

as  much  as  possible.  There  is  a  difference  in  tone  when  heard 
through  a  relaxed  muscle  and  through  one  in  a  state  of  con- 
traction. This  can  be  readily  proved  by  examining  through  the- 
trapezius  when  the  shoulder  is  raised,  relaxing  it,  and  when  the 
muscle  is  taut  as  it  is  when  the  hand  is  placed  on  the  opposite 
shoulder;  or  by  listening  through  the  pectoralis  when  the  arm 
is  thrown  forward  relaxing  and  then  thrown  backward  with  the 
arm  near  the  side  putting  it  on  the  stretch.  Through  the  re- 
laxed muscle  the  tone  is  soft  and  breezy,  while  through  the  con- 
tracted muscle  it  is  harsher,  sometimes  rougher  than  normal,  and 
of  higher  pitch.  To  appreciate  the  effect  of  different  thicknesses 
of  muscle  on  the  auscultatory  note,  let  the  examiner  listen  in 
the  axilla  and  compare  it  with  the  note  on  the  lower  folds  of  the 
pectoralis  immediately  above. 

It  is  very  important  to  appreciate  this  muscle  element  in  the 
respiratory  sound.  While  the  sound  heard  on  auscultation  is  pri- 
marily a  respiratory  affair,  it  is  modified  by  the  pulmonary  tis- 
sue, the  bony  cage  and  the  soft  parts.  Muscle  movements  of  them- 
selves emit  quite  a  note.  This  can  be  easily  determined  by  lis- 
tening through  the  stethoscope  to  the  biceps  while  the  muscle  is 
at  work.  It  will  also  be  noted  that  the  difference  in  the  note 
heard  on  easy  contraction  and  on  forced  contraction  is  marked, 
the  latter  being  not  unlike  the  changes  noted  in  the  respiratory 
note  in  the  presence  of  slight  pathological  conditions  in  the  pul- 
monary parenchyma. 

There  is  no  doubt  that  the  reflex  increased  tone  (spasm)  of  the 
apical  muscles  is  an  element  in  the  altered  sounds  that  we  hear 
in  early  tuberculosis  the  same  as  it  is  in  the  altered  percussion 
and  palpatory  findings.  How  much  of  an  element  it  is  cannot 
be  accurately  stated,  but  that  it  is  important  cannot  be  doubted. 

Respiratory  Sounds  in  Early  Tuberculosis. — There  is  no  definite 
change  in  the  respiratory  note  which  is  always  present  in  early 
tuberculosis.  If  there  was  it  would  be  a  comparatively  easy  mat- 
ter to  make  early  diagnoses  on  stethoscopic  findings.  There  is 
also  a  confusion  of  terms,  one  man  calling  a  given  sound  harsh, 
another  calling  it  rough.  Part  of  this  confusion  is  due  to  the 
changes   which  sound  undergoes   in  passing   through  different 


430  DIAGNOSIS   OF  EARLY   PULMONARY   TUBERCULOSIS 

stethoscopes,  and  part  of  it  to  the  different  methods  of  breath- 
ing during  auscultation.  The  degree  of  roughness  and  harshness 
is  often  accentuated  by  deep  breathing.  It  is  important  to  re- 
member that  there  are  several  changes  in  the  auscultatory  note 
in  early  tuberculosis,  one  or  more  of  which  may  be  present.  A 
very  common  condition  is  what  is  called  roughened  breathing. 
1  call  this  condition  when  very  marked  "near  rales"  because 
the  sensation  present  suggests  that  the  sound  is  about  to  burst 
into  rales.  Others  characterize  it  as  a  condition  of  stickiness. 
The  note  is  sometimes  slightly  harsh  with  higher  pitch  than  nor- 
mal. The  expiration  may  be  prolonged.  An  important  condition 
is  that  of  weakened  breathing  or  "impeded  breathing,"  as  I  pre- 
fer to  call  it.  The  breathing  is  not  full  and  free.  Air  enters  as 
though  against  an  impediment,  and  the  sounds  are  not  as  full 
and  loud  as  normal.  Rales  may  or  may  not  be  present.  In  truly 
early  clinical  tuberculosis  they  will  usually  be  absent;  and  if 
present  it  will  be  necessary  to  listen  to  a  deep  breath  following 
coughing  in  order  to  detect  them. 

Weakened  and  Roughened  Breathing. — This  type  of  breathing 
is  often  found ;  in  fact  is  an  almost  constant  accompaniment  of 
early  infiltrations  of  the  apex.  Brecke4  quotes  Striimpell,  Tur- 
ban, Knopf,  A.  Frankel,  Rumpf,  and  Bandelier  and  Roepke  as 
agreeing  that  the  earliest  alterations  in  the  auscultatory  note 
in  apical  tuberculosis  is  a  change  to  weak  and  rough.  Many 
different  causes  have  been  suggested  for  rough  breathing;  one, 
the  interference  with  the  air  entering  the  acini;  another,  se- 
cretion in  the  air  passages ;  another,  an  admixture  of  sounds  pro- 
duced by  secretion  and  the  normal  pulmonary  sound;  and  still 
another  suggested  by  Waller,  the  sound  produced  by  the  con- 
tracting respiratory  muscles.  Brecke  then  states  that  the  weak- 
ened breathing  has  not  been  explained. 

Another  very  common  condition  found  in  early  tuberculosis 
is  a  diminished  respiratory  murmur.  It  seems  perfectly  evident 
to  me  that  the  condition,  as  well  as  the  action  of  the  muscles  is  a 
factor  in  its  production.  While  it  is  probable  that  the  lessened 
elasticity  of  the  lung  tissue  is  a  factor,  the  lessened  inspiratory 


4Brauer,  Schroder,  und  Blumenfeld:     Handbuch  der  Tuberkulose,  Bd.  i,  1914. 


IMPEDED    BREATHING  431 

excursion  of  the  side  which  is  at  least  partly  a  reflex  phenomenon 
is  equally  important  and  the  effect  of  the  altered  tone  of  the 
muscles  upon  the  transmission  of  the  sound  must  be  considered. 
At  times  an  adherent  thickened  pleura  becomes  an  additional 
factor.  In  considering  the  muscle  element,  not  only  the  action  of 
the  apical  muscles  but  that  of  the  diaphragm  as  well  must,  be 
kept  in  mind.  The  fibers  of  all  of  these  are  thrown  into  a  state 
of  increased  tone  (spasm)  which  limits  the  free  motion  of  the 
entire  side  of  the  chest,  thus  reducing  the  force  of  the  respira- 
tory murmur.  That  portion  of  the  lung  which  is  the  seat  of  in- 
filtration offers  extra  obstacles  to  the  ingress  of  air  as  compared 
with  the  uninfiltrated  lung;  consequently  it  may  show  a  marked 
degree  of  weakening  of  the  note. 

Quoting  from  a  previous  paper:5 

"I  have  described  this  complex  picture  presented  to  the  ear 
in  early  tuberculosis  as  'impeded  breathing ; r  meaning  by  this 
that  the  air  enters  the  lung  as  though  it  were  forcing  its  way 
against  obstacles.  The  murmur  instead  of  being  smooth  and  of 
its  usual  volume  seems  to  be  diminished,  somewhat  rougher,  and 
harsher  than  normal.  I  am  now  convinced  that  much  of  the 
change  is  caused  by  the  contracted  muscles  rather  than  the  air 
in  the  lung. 

"It  will  be  noted  also  that  the  auscultatory  sound,  as  well  as 
the  data  obtained  on  percussion,  are  different  near  the  sternum 
and  in  the  middle  of  the  first  interspace  between  the  deltoid  and 
pectoral  muscles  from  that  found  over  the  muscle  masses. 

"I  do  not  wish  to  be  understood  as  claiming  that  all  the 
changes  which  we  find  on  auscultation  are  due  to  the  muscle 
condition,  but  I  wish  to  call  attention  to  the  fact  that  there  is  a 
muscular  element  in  all  auscultatory  findings  in  the  chest  and 
that  the  auscultatory  sound  in  early  tuberculous  infections  is 
especially  influenced  by  the  underlying  contracting  muscles.  Af- 
ter severe  changes  such  as  dense  infiltration,  which  lead  to  the 
formation  of  scar  tissue  and  cavity  formation  in  tuberculosis, 
and  such  as  occur  when  other  pulmonary  diseases  are  present  in 


6Pottenger:  The  Importance  of  the  Neck  and  Chest  Muscles  in  the  Production  of  the 
Phenomena  Obtained  by  Percussion  and  Auscultation  of  the  Chest,  Archives  of  Diagnosis, 
October,  1910. 


432  DIAGNOSIS   OF  EARLY   PULMONARY   TUBERCULOSIS 

the  lung,  the  muscular  element  probably  becomes  less  of  a  factor 
and  the  pulmonary  tissue  more  of  a  factor  in  the  production  of 
the  auscultatory  sounds. 

"The  muscle  element  has  been  recognized  in  examination  of 
the  chest  unknowingly;  for  example,  teachers  of  physical  diag- 
nosis, and  authors  of  text-books,  often  tell  us  that  if  we  wish 
to  fix  in  our  minds  the  normal  -vesicular  respiratory  murmur,  it 
is  best  to  listen  in  the  axilla.  The  reason  for  this  is  not  that  the 
sound  heard  there  is  any  purer  than  over  any  other  portion  of 
the  chest,  but  that  the  sound  is  less  affected  by  muscles,  because 
there  are  no  fleshy  muscles  covering  the  chest  in  the  axilla." 

The  part  that  the  muscles  play  in  the  production  of  the  sound 
heard  on  auscultation  may  be  realized  by  comparing  the  ausculta- 
tory sounds  heard  over  a  rigid  thorax  or  over  the  thorax  of  one 
who  practices  abdominal  breathing  with  one  who  uses  the  thoracic 
muscles  in  the  normal  manner.  The  lungs  are  inflated  in  the 
former  condition  the  same  as  in  the  latter.  The  pulmonary  tis- 
sue is  distended,  but  the  sounds  are  wTeak,  at  times  almost  in- 
audible, and  much  smoother  than  when  the  muscles  exert  their 
influence  more  strongly  upon  the  sounds. 

Not  only  do  the  chest  muscles  influence  the  respiratory  sounds 
as  they  are  conducted  through  them  to  the  ear,  but  they  also 
produce  sounds  which  are  difficult  at  times  to  distinguish  from 
intrapulmonary  rales.  One  can  satisfy  himself  on  this  point  very 
readily  by  listening  over  a  chest  in  which  the  pulmonary  tissue 
is  collapsed  as  a  result  of  pneumothorax  or  empyema.  At  times, 
sounds  which  are  difficult  to  distinguish  from  intrapulmonary 
rales,  are  heard  over  the  apices  of  the  lungs. 

Why  Respiratory  Sounds  Differ  in  Early  Tuberculosis. — A  dis- 
cussion of  why  the  auscultatory  sounds  differ  in  different  patients 
suffering  from  early  tuberculosis  is  of  great  importance  in  eluci- 
dating this  most  difficult  yet  most  important  procedure  in  physi- 
cal diagnosis. 

Sounds  may  vary  in  different  patients  according  to  the  con- 
ditions which  produce  them  and  the  condition  of  the  tissues  which 
transmit  them.  The  voice  itself  differs  materially  in  different 
individuals.    The  character  of  the  breathing  is  a  variable  factor. 


WHY   RESPIRATORY  SOUNDS  DIFFER  433 

The  amount  of  soft  tissues,  subcutaneous  and  muscular  differs 
greatly.  The  character  of  these  tissues,  whether  flabby  or  firm, 
and  particularly  the  state  of  the  muscles,  whether  they  are  in 
contraction,  relaxation,  or  whether  they  show  degeneration  is 
important.  The  state  of  the  bony  thorax  whether  elastic  or 
fixed  makes  some  difference  also. 

Another  important  factor  in  the  variability  of  the  ausculta- 
tory note  is  the  pathological  conditions,  other  than  of  tubercu- 
lous origin,  affecting  the  lung  itself.  The  lung  is  often  in  an  ab- 
normal state.  It  may  be  emphysematous;  it  may  be  the  seat  of 
fibrosis  resulting  from  a  previous  pneumonia  or  tuberculosis; 
it  may  be  altered  because  of  an  old  pleurisy  or  empyema  or  it 
may  be  modified  by  the  fact  that  we  have  a  new  activity  in  an 
old  focus.  All  of  these  factors  tend  to  make  a  difference  in  the 
note  to  be  heard  even  in  what  might  be  considered  as  early 
clinical  signs.  If  we  were  always  listening  to  a  new  infiltration 
in  a  lung  which  had  been  normal  hitherto,  the  matter  would  be 
comparatively  simple. 

To  my  mind  the  harsh  and  "high  pitched  characteristics  are 
fundamental  and  more  prominent  than  the  rough  element  when 
we  have  a  lighting  up  of  activity  in  an  old  focus  providing  it  is 
sufficiently  extensive  to  result  in  fibrosis  of  considerable  amount. 
Here  the  prolonged  expiration  is  also  most  marked.  This  is  also 
marked,  however,  if  the  new  infiltration  is  extensive.  The  purest 
rough  breathing,  on  the  other  hand,  comes  in  the  apex  involved 
for  the  first  time.  Impeded  breathing  comes  under  both  condi- 
tions but  shows  best  in  the  newly  involved. 

Interpretation  of  Auscultatory  Findings. — Findings  on  ausculta- 
tion must  be  interpreted,  as  a  rule,  in  connection  with  the  clinical 
history.  Now  and  then  positive  incontrovertible  evidence  of 
early  clinical  pulmonary  tuberculosis  will  be  found  on  ausculta- 
tion without  any  symptoms  being  present  which  the  patient  has 
recognized ;  but  this  is  rare.  As  a  rule,  symptoms  will  be  present 
under  these  conditions.  Rales  localized  at  one  apex  are  very 
significant ;  in  fact,  the  most  significant  of  auscultatory  signs ;  but, 
they  are  present  in  only  a  small  proportion  of  early  tuberculous 
cases  and  should  not  be  expected.  They  come  after  the  diffu- 
sion of  toxins  has  produced  a  collateral  inflammation  with  exuda- 


434  DIAGNOSIS   OF  EARLY  PULMONARY   TUBERCULOSIS 

tion  in  the  tissues.  Rough  breathing,  or  rough  harsh  breathing, 
or  localized  impeded  breathing  are  very  suspicious,  and  if  ac- 
companied by  clinical  symptoms  warrant  a  positive  diagnosis. 
When  these  are  significant  of  an  active  tuberculous  process,  some 
degree  of  lagging  will  nearly  always  be  present  if  looked  for  in 
a  painstaking  way;  an  increased  tone  (spasm)  of  some  of  the 
apical  muscles  will  usually  be  found;  and,  a  prompt  maximum 
tuberculin  reaction  will  usually  occur. 

Whispered  Voice. — An  intense  whispered  voice  is  of  some  value. 
This  presupposes  a  pathological  area  of  some  magnitude,  how- 
ever. To  determine  this  a  syllable  should  be  chosen  which  can 
be  drawn  out.  "  Whis-per-r-r-r, "  with  emphasis  on  the  last 
syllable  is  splendid,  or  the  words,  "one,  two,  three"  may  be 
used.  Sewall6  recommends  that  the  stethoscope  be  pressed  firmly 
to  the  surface  of  the  chest  in  order  to  eliminate  the  muscle  ele- 
ments of  the  sound  as  much  as  possible ;  and  that  the  words  ' '  one, 
two,  three"  be  spoken  staccato.  If  infiltration  is  present,  in  spite 
of  the  staccato  whisper  the  tones  will  be  fused.  This  method 
seems  to  have  considerable  value  and  when  understood  is  not 
difficult  to  put  into  practice. 


transactions  American  Climate-logical  Association,  1913. 


CHAPTER  XVI. 

THE  SIGNS  AND  SYMPTOMS  OF  ADVANCED  PULMONARY 

TUBERCULOSIS. 

General  Considerations. — Advanced  pulmonary  tuberculosis  is 
an  extension  from,  the  primary  metastasis  in  the  lung.  The  dis- 
ease is  more  widely  spread  and  its  pathology  more  varied.  It 
shows  all  of  the  degenerative  changes,  as  well  as  the  prolifera- 
tive changes  to  which  tubercles  are  subject.  Its  symptomatology 
differs  from  that  of  early  tuberculosis  not  only  in  that  the  symp- 
toms are  more  pronounced,  but  because  new  symptoms  are  added 
as  the  pathological  changes  become, more  advanced.  Prom  the 
prognostic  standpoint,  in  comparison  with  the  early  lesion,  it  is 
much  more  serious.  It  seems  best,  therefore,  for  the  physician 
to  bear  in  mind  two  distinct  pictures, — one  that  of  early  tuber- 
culosis, the  other  that  of  late  tuberculosis;  consequently,  in  my 
description  I  have  treated  them  separately,  although  such  a  course 
calls  for  what  might  be  considered  unnecessary  repetition. 

Early  tuberculosis  is  a  localized  infection  in  the  lung  which 
produces  clinical  symptoms  usually  of  a  mild  character;  and  is 
attended  by  a  favorable  prognosis.  Advanced  tuberculosis  con- 
sists of  an  infection  in  the  lung  which  shows  a  marked  tendency 
to  spread  and  which  produces  symptoms  of  a  varied  nature  in- 
volving every  important  organ  of  the  body.  The  results  of  ad- 
vanced tuberculosis  are  serious  and  permanent;  and,  while  a 
clinical  arrestment  can  often  be  obtained,  yet  it  is  impossible  to 
restore  the  tissue  which  has  been  involved  in  the  inflammation. 

The  clinical  symptoms  of  advanced  tuberculosis  are  those 
which  attend  a  more  or  less  extensive  inflammatory  process,  a 
variable  degree  of  toxemia,  and  a  process  which  is  accompanied 
by  more  or  less  displacement  of  or  destruction  of  tissue.  They 
differ  greatly  in  their  severity  according  to  the  pathological 
changes  which  predominate.  If  the  disease  is  of  the  fibroid  type, 
in  which  new  tissue  formation  predominates,  the  symptoms  are 


436  SIGNS  AND  SYMPTOMS   OF  PULMONARY  TUBERCULOSIS 

less  severe  than  where  the  exudative  and  ulcerative  type  pre- 
dominates. Fibroid  tuberculosis,  however,  reaches  a  point  at 
times  when  the  symptoms  which  arise,  as  a  result  of  the  patho- 
logical changes,  are  more  important  than  those  produced  by  the 
disease  process  itself. 

Variability  of  symptoms  is  due  partly  to  the  individuality  of 
the  patient.  As  described  elsewhere  in  these  pages,  all  people  are 
not  constructed  after  the  same  pattern.  There  are  differences  in 
body  form,  in  the  stability  of  nerve  centers,  and  in  the  stability 
of  the  function  of  organs.  Consequently,  the  nerve  action  which 
produces  disturbed  function  or  symptoms  is  produced  by  weaker 
stimuli  in  some  patients  than  in  others. 

The  importance  of  careful  diagnosis  in  advanced  tuberculosis 
cannot  be  overestimated.  It  is  not  sufficient  to  know  that  tuber- 
culosis is  present.  For  this  a  physician  is  rarely  necessary  when 
the  advanced  disease  is  present,  but  the  prognosis  and  proper  ap- 
plication of  therapeutic  measures  requires  a  careful  estimate  of 
the  condition  within  the  chest  and  a  proper  estimate  of  the  work- 
ing capacity  of  the  other  important  systems  and  organs;  con- 
sequently, the  more  careful  our  examination  and  the  more  ac- 
curate our  diagnosis,  the  greater  our  ability  to  intelligently  treat 
the  patient. 

The  family  and  personal  history  in  advanced  tuberculosis  is 
practically  the  same  as  that  in  early  tuberculosis.  The  reader 
may  refer  to  Chapter  XIV  for  a  discussion  of  this  subject. 

It  is  very  important  to  know  that  tuberculosis  is  a  disease 
which  runs  an  uneven  course.  It  is  marked  by  alternating 
periods  of  activity  and  quiescence.  The  disease  often  extends 
over  a  period  of  several  years,  during  which  time,  from  the  small 
beginning  at  one  apex,  or  at  the  hilus,  there  is  a  succession  of 
extensions  until  the  entire  pulmonary  parenchyma  is  involved. 
Advancements  of  the  disease,  as  well  as  increases  in  its  activity, 
are  accompanied  by  an  exacerbation  of  symptoms ;  and  each  period 
of  quiescence  is  accompanied  by  a  remission  of  symptoms.  In 
case  the  disease  is  not  checked,  these  periods  of  extension  and  ac- 
tivity are  increased  until  finally  the  entire  pulmonary  area  is  more 
or  less  involved  and  the  patient's  life  is  extinguished. 

Classification  of  Symptoms  of  Advanced  Tuberculosis. — The 


CLASSIFICATION   OF   SYMPTOMS 


437 


symptoms  of  advanced  tuberculosis  may  be  classed  under  four 
heads,  according  to  their  etiology,  as  follows: 


Group  I. 

Group  II. 

TOXEMIA. 

REFLEX    ORIGIN. 

Headache 

Hoarseness 

Malaise 

Tickling  in  larynx 

Lack  of  endurance 

Cough 

Loss  of  strength 

Circulatory  disturbances 

Nervous  instability 

Digestive  disturbances 

Insomnia 

Loss  of  weight 

Loss  of  appetite 

Anorexia 

Digestive  disturbances 

Vomiting 

Loss  of  weight 

Chest  and  shoulder  pains 

Circulatory  disturbances 

Hectic  flush 

Night  sweats 

Apparent  anemia 

Temperature 

Blood  changes 

- 

Group  III. 

Group  IV. 

tuberculous  process  per  se. 

AS  RESULTS  OF  TUBERCULOSIS. 

Frequent  and  protracted  colds 

Eespiratory  changes 

Spitting  of  blood 

Dyspnea 

Pleurisy 

Circulatory  changes 

Sputum 

Cyanosis 

Fever 

Changes  on  part  of  nervous  system 

Changes  in  blood 

General  metabolic  changes 

Degenerative  changes 

Menstrual  irregularities 

The  symptoms  designated  as  belonging  to  the  toxic  group  play 
an  important  part  in  the  clinical  history  of  advanced  active  tuber- 
culosis. They  are  prominent  in  nearly  every  case  as  long  as  clinical 
activity  is  present.  They  are  comparatively  slight  in  fibroid 
tuberculosis  and  may  be  very  severe  in  acute  ulcerative  tuber- 
culosis, and  moderately  severe  in  the  combined  types.  Their 
severity  depends  on  the  degree  of  activity.  They  are  accentuated 
by  exertion  and  mental  depression.  It  is  difficult  to  specify 
which  group  of  symptoms  is  most  important  in  advanced  tuber- 
culosis, for  we  are  not  dealing  with  them  from  the  standpoint 
of  diagnosis,  as  much  as  from  the  standpoint  of  their  effect  on 
prognosis.     The  importance  of  the  individual  symptoms  varies 


438  SIGNS  AND   SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

from  time  to  time,  now  one  predominating  and  now  another. 
The  toxic  symptoms,  however,  being  an  expression  of  central  irrita- 
tion plus  general  sympathetic  inhibition,  are  extremely  deleteri- 
ous. Those  symptoms  on  the  part  of  the  various  organs  which 
result  from  the  disease  itself,  finally  assume  greater  importance 
than  they  do  when  accompanying  the  earlier  stages  of  the  dis- 
ease. 

In  Chapter  XIV  dealing  with  early  symptoms  I  endeavored  to 
show  how  the  three  etiological  factors  entered  into  the  causation 
of  each  symptom.  In  the  present  discussion,  however,  I  shall  dis- 
cuss each  symptom  as  a  whole,  but  would  refer  my  readers  to  the 
previous  discussion  for  greater  detail  in  etiology.  Oftentimes  in 
advanced  tuberculosis  those  symptoms  which  result  from  the  dis- 
ease are  more  serious  than  those  actively  caused  by  it. 

Malaise,  Lack  of  Endurance,  Loss  of  Strength. — These  symp- 
toms show  themselves  early  in  the  disease  with  the  beginning  of 
activity,  and  continue,  with  periods  of  relief  intervening,  as  a 
very  important  part  of  the  clinical  history  until  the  end  of  the 
disease.  The  seriousness  of  these  symptoms  may  be  appreciated 
by  knowing  that  they  are  primarily  due  to  the  effect  of  harm- 
ful stimulation  of  the  nerve  centers  in  the  central  nervous  sys- 
tem. They  are  exaggerated  at  the  time  of  each  exacerbation, 
and  disappear  partly  or  wholly  during  periods  of  quiescence, 
particularly  if  the  patient  is  kept  quiet.  Sometimes  loss  of 
strength  is  so  marked  that  even  the  slightest  exertion  seems  to 
require  more  effort  than  the  patient  can  make.  Mental  tiring 
is  no  less  important  and  no  less  prominent  than  physical  tiring. 
Symptoms  on  the  part  of  the  nervous  system  are  varied  and  of 
great  interest.  Toxins  from  the  tubercle  bacilli,  as  well  as  toxic 
substances  which  are  produced  in  the  necrotic  tissue,  likewise 
those  which  are  stored  up  in  the  body  as  a  result  of  the  tubercu- 
lous process  all  act  centrally,  then  express  their  effect  particularly 
upon  the  sympathetic  nervous  system,  inhibiting  normal  func- 
tion. Neurasthenia,  which  is  an  accompaniment  of  early  tuber- 
culosis, often  becomes  extremely  marked  in  some  of  the  advanced 
cases.  Psychoses  are  also  at  times  present.  The  exaggerated 
emotional  states  as  mentioned  in  Chapter  VI  are  here  greatly 
intensified.     For  a  further  description  of  the  symptoms  which 


DIGESTIVE   DISTURBANCES  439 

arise  on  the  part  of  the  nervous  system  I  would  refer  to  Chap- 
ters VI,  VII  and  VIII. 

Digestive  Disturbances. — These  symptoms  in  advanced  tuber- 
culosis are  varied,  and  very  important  from  the  standpoint  of 
nutrition.  That  they  should  be  pronounced  at  times  is  self-evi- 
dent. Patients  suffering  from  advanced  tuberculosis  are  victims 
of  a  toxemia  not  only  due  to  the  tubercle  bacilli,  but  resulting 
from  necrotic  tissue  as  well,  which  produce  a  marked  inhibiting 
action  on  all  the  vital  functions,  greatly  interfering  with  the 
appetite,  with  digestion  and  assimilation.  Reflex  irritation  of 
the  vagus  is  also  present.  The  symptoms  may  vary  from  a  slight 
anorexia  to  a  complete  disgust  for  food,  or  even  vomiting.  The 
degree  of  severity  depends  quite  often  upon  the  amount  of  ac- 
tivity present  in  the  lung,  although  not  wholly  so.  We  at  times 
see  patients  go  through  periods  of  high  fever  and  marked  de- 
structive changes  in  the  pulmonary  tissue  with  little  or  no  dis- 
turbance in  appetite.  On  the  other  hand,  it  is  extremely  com- 
mon, in  fact  the  rule,  to  find  a  partial  or  general  inhibition  of 
action  on  the  part  of  the  digestive  system  every  time  an  acute 
inflammation  in  the  pulmonary  tissue  takes  place.  Not  only  the 
toxemia,  but  the  reflex  disturbances  in  the  equilibrium  of  the 
organs,  which  gradually  results  from  a  generally  decreased  nerve 
tone,  as  the  disease  advances  in  severity,  is  an  important  factor 
for  consideration.  For  a  further  discussion  of  this  interesting 
question  see  Chapter  X. 

The  damming  back  of  the  blood  in  the  splanchnic  areas,  as 
described  in  Chapter  XI,  has  a  marked  effect  in  the  production 
of  symptoms.  The  digestion  also  suffers  from  the  general  wast- 
ing not  only  of  the  muscles  but  of  the  cells  in  general.  The  en- 
forced quietude  of  the  patient  also  has  a  deleterious  effect  upon 
the  body  as  well  as  the  digestion.  All  of  the  common  forms  of 
stomach  and  intestinal  disturbances  are  found,  such  as  hyper- 
chlorhydria,  hypochlorhydria,  hypermotility,  atrophy  with  dila- 
tation, stasis,  displacement,  and  constipation,  and  it  is  character- 
istic of  all  of  them  that  they  are  more  stubborn  and  more  difficult 
to  treat  than  they  would  be  in  individuals  who  are  not  suffering 
from  toxemia,  whose  vegetative  nervous  equilibrium  is  less  dis- 


440  SIGNS  AND  SYMPTOMS   OF   PULMONARY   TUBERCULOSIS 

turbed,  and  whose  tissue  tone  is  on  a  higher  plane,  and  who  do 
not  suffer  from  continuous  splanchnic  congestion.  During  the 
acuteness  which  accompanies  cavity  formation,  anorexia  and 
vomiting  are  not  uncommon.  They  occur  with  cough  or  any  dis- 
turbance of  nerve  balance,  showing  that  they  have,  at  least  par- 
tially, a  reflex  origin.  Hyperstimulation  or  hyperirritability  of  the 
vagus  is  the  probable  cause.  Nausea  and  vomiting  may  be  a 
part  of  a  chain  of  symptoms  which  are  due  to  definite  gastro- 
intestinal disease;  and  this  must  be  thought  of  in  diagnosis. 
Vomiting,  on  the  other  hand,  often  comes  on  reflexly  with  cough. 
Sometimes  it  seems  to  be  associated  with  a  reflex  irritability  of 
the  pharynx,  and  when  mucus  collects  on  the  pharyngeal  wall 
vomiting  ensues.  This  is  especially  prone  to  occur  in  the  early 
morning  when  the  patient  is  expelling  the  mucus  which  has 
collected  over  night,  particularly  if  it  is  tenacious. 

Structural  changes  in  the  intestinal  tract  are  not  necessarily 
present,  even  when  the  symptoms  are  pronounced.  The  tongue 
shows  the  same  changes  as  in  the  non-tuberculous.  There  is 
usually  a  slight  coating  of  fur,  at  least,  in  nearly  all  cases  of  ad- 
vanced active  tuberculosis.  During  the  periods  of  acute  activity, 
with  extension  of  the  disease;  or,  during  the  time  when  acute 
caseation  is  taking  place,  sympathetic  inhibition  is  present,  as  a 
rule,  and  the  gastrointestinal  symptoms  become  more  acute.  The 
coating  on  the  tongue  thickens,  the  entire  organ  may  become 
dry,  appetite  lessens  and  the  digestive  capabilities  decrease.  The 
added  toxemia  is  probably  the  chief  element  in  the  production 
of  the  greater  disturbances.  The  central  stimulating  effect  on 
the  sympathetics  caused  by  the  toxins  and  depressive  emotional 
states  when  added  to  the  peripheral  stimulation  which  takes 
place  as  a  result  of  increased  adrenin  secretion  is  sufficient  to 
overbalance  the  vagus  tonus  and  produce  the  effects  mentioned. 

Other  symptoms  on  the  part  of  the  gastrointestinal  tract  are 
described  more  fully  in  Chapter  X. 

Loss  of  Weight. — Loss  of  weight  at  times  becomes  a  very  im- 
portant symptom  in  advanced  tuberculosis.  It  is  not  uncommon 
in  the  far  advanced  disease  to  see  a  loss  of  one-third  of  the  body 
weight,  and  this  is  often  exceeded  prior  to  death.  A  loss  of 
weight  of  itself  is  not  so  serious  a  matter.    All  patients  will  lose 


LOSS   OF  WEIGHT  441 

some  at  times,  particularly  if  they  are  not  properly  conserving 
their  strength.  During  the  period  when  the  disease  is  active,  even 
though  it  is  not  accompanied  by  fever,  overexertion  is  prone  to 
turn  the  balance  against  the  patient  and  cause  loss  of  weight. 
A  loss  is  also  to  be  expected  during  the  period  when  the  patient 
is  having  fever. 

It  also  comes  at  times  when  the  patient  is  worried  or  anxious 
or  pessimistic.  A  happy  frame  of  mind  under  certain  condi- 
tions of  the  disease  is  essential  to  the  maintenance  of  proper  body 
weight.  The  inhibiting  influence  of  discontent  and  discourage- 
ment upon  the  gastrointestinal  canal  at  times  is  the  greatest 
factor  in  preventing  proper  gain  in  weight. 

After  patients  have  been  ill  for  a  long  time  and  have  developed 
large  amounts  of  fibrosis  in  the  lung,  with  its  consequent  reduced 
pulmonary  area,  and  its  accompanying  heart  strain,  they  are  apt 
to  assume  a  weight  several  pounds  below  their  normal  and  be 
unable  to  increase  it  to  any  great  extent  even  though  the  disease 
is  quiescent.  I  take  this  to  be  physiological  or  compensatory; 
and,  look  upon  the  new  weight  level,  although  it  may  be  several 
pounds  below  the  normal,  as  being  best  for  the  patient  under  the 
new  conditions  of  respiratory  and  circulatory  limitations.  The 
patient  cannot  maintain  as  much  flesh  under  the  new  conditions 
as  under  the  old ;  yet  seems  to  be  in  a  good  state  of  health  with 
the  low  level.  Often  such  patients  will,  after  a  time,  when  the 
heart  has  strengthened  and  the  general  cellular  activities  have 
improved,  put  on  weight  without  any  change  in  the  character 
or  any  increase  in  the  amounts  of  food  taken.  When  this  takes 
place,  I  look  upon  it  as  a  good  indication. 

While  gaining  in  weight  is  often  desirable  and  while  the  phy- 
sician prefers  to  see  his  patients  up  to  their  normal  standard,  it 
can  readily  be  understood  that  there  are  conditions  under  which 
this  cannot  be,  except  to  the  detriment  of  the  patient.  There  are 
many  times  in  the  course  of  tuberculosis  when  putting  on  weight 
or  maintaining  the  body  weight  can  only  be  done  at  the  expense 
of  the  patient,  and  the  cost  is  too  great  for  the  supposed  gain. 
The  gain  is  psychical,  the  danger  done  is  material. 

If  one  could  only  put  the  patient's  mind  and  the  minds  of  his 


442  SIGNS  AND   SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

friends  in  the  right  attitude  on  this  important  question,  much 
anxiety  and  fretting  could  be  avoided,  and  the  fight  for  health 
would  be  an  easier  one.  But  the  impossible  is  expected.  The 
gain  in  weight  is  taken  as  the  index  to  the  patient's  improve- 
ment, because  it  is  perceptible.  He  is  expected  to  gain  no  mat- 
ter what  pathological  changes  are  going  on  in  his  lungs  and  no 
matter  what  the  state  of  his  general  nerve  and  cell  tone.  Not 
only  is  a  gain  expected  to  take  place,  but  no  loss  of  weight  is  ex- 
pected under  any  circumstances.  Many  men  continue  the  prac- 
tice of  forced  feeding  when  they  know  it  is  wrong,  simply  because 
of  this  unreasonable  demand  for  a  gain  in  weight. 

Circulatory  Disturbances. — The  symptoms  on  the  part  of  the 
circulatory  system,  which  come  on  in  the  earlier  part  of  the  dis- 
ease, are  of  toxic  and  reflex  origin;  but,  later,  those  which  are 
a  result  of  the  disease,  become  even  more  important.  The  symp- 
toms are  slight  in  early  cases  and  of  all  degrees  of  severity  in  the 
advanced  ones,  depending  on  the  particular  pathology  present. 
For  a  more  complete  discussion  see  Chapter  IX. 

The  importance  of  a  good  heart  to  the  tuberculous  patient 
cannot  be  overestimated,  for  it  is  the  organ  which  must  bear  the 
brunt  of  the  disease.  It  is  subject  to  the  influence  of  the  tox- 
emias which  occur  both  as  a  result  of  the  tuberculous  process 
and  those  due  to  other  causes.  It  suffers  with  other  structures  of 
the  body  in  the  general  malnutrition  and  degeneration;  and  it 
bears  the  brunt  of  the  disease  in  being  compelled  to  keep  up  the 
circulation  under  the  changed  conditions  as  they  exist  as  a  re- 
sult of  the  destroyed  pulmonary  tissue,  the  altered  respiratory 
action,  and  the  general  nerve  disturbance  present. 

Quoting  from  the  author's  former  monograph:1 

"In  order  to  fully  appreciate  the  enormous  strain  which  is 
put  upon  the  heart,  we  must  consider,  first,  that  chronic  tuber- 
culosis of  the  lungs  is  a  chronic  pneumonic  process ;  second,  that 
as  the  process  advances,  it  destroys  the  blood  vessels  and  also 
destroys  the  normal  lung  tissue  and  substitutes  for  it  either  cav- 
ities or  cicatricial  tissue ;  third,  with  the  advance  of  the  disease, 
contraction  takes  place  in  one  portion  of  the  lung,  while  other 


Pulmonary  Tuberculosis,  William  Wood  &  Co.,  New  York,  1908. 


CIRCULATORY  DISTURBANCES  443 

portions  enlarge,  becoming  emphysematous,  to  establish  compen- 
sation ;  and,  fourth,  the  advanced  disease  is  accompanied  by  more 
or  less  catarrhal  inflammation  of  the  air  passages. 

"All  of  these  conditions  tend  to  embarrass  the  right  heart,  thus 
damming  back  the  blood  in  the  systemic  circulation  as  well. 

"The  heart  often  learns  to  accommodate  itself  to  the  enormous 
strain  that  is  thrown  upon  it  because  the  changes  come  gradually, 
taking  months  and  years  to  effect  them.  On  the  other  hand,  if 
the  same  amount  of  resistance  were  opposed  to  the  heart  sud- 
denly, by  an  acute  process,  the  result  could  be  none  other  than 
disastrous. 

"The  rapidity  and  efficiency  of  the  heart's  action,  then,  must 
always  receive  careful  attention  in  giving  a  prognosis." 

The  heart  beat  is  usually  increased  in  frequency  as  long  as  the 
disease  is  acute,  although  there  are  exceptions  to  this  rule.  The 
particular  characteristic  of  the  heart  in  advanced  active  tuber- 
culosis, however,  is  that  it  is  not  able  to  measure  up  to  extra 
exertion.  It  may  be  normal  in  its  frequency,  or  only  slightly 
above  when  at  rest,  but  increases  greatly  on  extra  demand.  Such 
a  heart  also  returns  to  its  normal  beat  slowly. 

"When  the  body  is  called  on  for  extra  work  it  requires  extra 
blood.  This  must  be  drawn  from  the  great  splanchnic  reservoir; 
but  in  tuberculosis,  owing  to  the  lessened  inspiratory  act,  there  is 
an  inability  to  furnish  this  extra  blood  as  needed,  and  even  if 
the  heart  were  normal  in  power  it  would  fail  to  measure  up  to 
the  demands  made  on  it.    Dyspnea  results. 

The  persistently  high  pulse  which  fails  to  yield  to  proper  treat- 
ment, is  usually  associated  with  conditions  which  call  for  a  bad 
prognosis  for  the  ultimate  outcome  of  the  patient.  It  either 
shows  a  condition  of  general  stimulation  through  the  sympa- 
thetic nervous  system  or  a  greatly  increased  effort  to  maintain 
the  circulatory  equilibrium.  A  pulse  which  drops  as  the  tempera- 
ture rises  is  suspicious  of  tuberculosis  of  the  intestinal  tract,  the 
lowering  effect  coming  through  the  depressor  branches  of  the 
vagus  (see  page  201).  This  is  also  seen  at  times  as  a  result  of  the 
reflex  stimulation  of  the  vagus  from  the  inflammation  in  the  lung, 
as  shown  in  Figs.  31  and  32,  pages  203,  204  and  205. 


444  SIGNS  AND  SYMPTOMS   OF   PULMONARY   TUBERCULOSIS 

The  blood  pressure  is  low  and  the  entire  vascular  tone  de- 
creased. 

The  heart  in  early  cases  is  often  smaller  than  normal.  I  have 
suggested  as  a  cause  of  this,  the  lessening  of  the  inspiratory  act 
which  causes  less  blood  to  be  delivered  to  the  right  heart  in  a 
given  time,  resulting  in  a  lessened  content  of  blood  and  a  phys- 
iological decrease  in  the  size  of  the  heart.  This  also  causes  a 
relatively  small  amount  of  blood  to  be  delivered  to  the  arteries, 
resulting  in  a  relative  arterial  anemia  with  lowered  blood  pres- 
sure. Wasting  of  the  tissues  is  also  a  factor  in  lowering  the 
blood  pressure  as  the  disease  advances. 

Later  in  the  disease,  the  right  heart  takes  upon  itself  a  com- 
pensatory hypertrophy,  the  organ  may  become  larger  than  nor- 
mal ;  but  this  may  again  give  way  later  as  the  heart  yields  to  the 
general  malnutrition  which  is  present  throughout  the  body. 

Whether  the  heart  is  larger  or  smaller  than  normal  cannot  be 
determined  in  a  haphazard  way.  The  postmortem  measurements 
which  are  of  value  in  determining  the  fact  that  the  heart  is 
smaller  than  normal  in  tuberculosis  are  those  which  have  been 
made  on  young  individuals  of  robust  build  who  have  died  of 
other  causes  during  the  time  that  their  disease  was  active,  but 
before  the  advanced  wasting  stage  has  been  reached.  The  clini- 
cal evidence  must  be  based  on  careful  measurements  of  the  same 
type  of  cases. 

The  clinical  measurements  which  prove  that  hypertrophy  of 
the  right  ventricle  occurs,  are  those  taken  during  a  chronic  pro- 
cess on  patients  in  whom  a  considerable  extra  strain  has  been 
thrown  on  the  heart  as  a  result  of  destructive  lung  changes. 
Postmortem  evidence  must  come  from  individuals  of  the  same 
type  who  die  of  accidental  cause  during  this  period  without  going 
on  to  a  stage  of  severe  wasting. 

The  measurements  of  the  heart  in  the  advanced  wasted  con- 
sumptive simply  prove  that  the  heart  has  taken  part  in  the  gen- 
eral process.  If  hypertrophy  is  marked  the  organ  may  be  larger 
than  normal.  If  not,  it  may  be  smaller,  but  such  measurements 
have  no  bearing  on  the  question  as  to  whether  or  not  tuberculosis 
is  preceded  or  accompanied  by  a  small  heart. 


NIGHT  SWEATS  AND  FEVER  445 

Night  Sweats. — Sweats  are  extremely  variable  in  tuberculosis. 
They  may  come  on  early  and  be  important  in  diagnosis  or  they 
may  be  scarcely  noticeable  during  the  entire  course  of  the  dis- 
ease. Sometimes  during  caseation  and  cavity  formation,  sweats 
are  so  severe  as  to  drench  the  bedding.  When  night  sweats  are 
present  some  degree  of  toxemia  is  usually  present.  They  are  a 
result  of  sympathetic  stimulation  in  early  tuberculosis,  but  we 
must  not  forget  that  sweating  is  also  a  part  of  the  vagus  syn- 
drome. 

Sweating  usually  occurs  when  the  patient  sleeps.  It  is  especially 
severe  whenever  fever  is  present  and  is  most  marked,  as  a  rule, 
when  rapid  destruction  of  tissue  is  taking  place  with  ab- 
sorption of  the  products  of  autolysis.  Under  these  circumstances 
toxemia  is  severe  and  the  diurnal  variation  in  temperature  is 
great.  As  the  patient  falls  asleep  the  temperature  drops,  and  a 
general  relaxation  of  the  superficial' vessels  takes  place  which  is 
followed  by  perspiration. 

Sweats  may  be  relieved  to  some  extent  by  improving  the  tone 
of  the  skin,  as,  for  example,  by  removing  extra  clothing,  and  by 
hardening  by  sun,  air,  and  water  baths.  Sweating,  while  com- 
mon in  tuberculosis,  is  not  peculiar  to  it,  but  may  occur  in  other 
toxemias  and  exhausting  diseases. 

Fever. — Fever  is  so  important  as  a  symptom  of  tuberculosis 
that  I  shall  discuss  it  at  length  in  a  separate  chapter  (see  Volume 
II,  Chapter  XXX).  Fever  itself  is  not  as  deleterious  as  is  usually 
thought.  It  is,  however,  a  tangible  expression  of  the  toxemia 
which  results  from  the  pathological  changes  going  on  in  the 
lung  and  as  such  aids  greatly  in  understanding  the  disease.  It 
is  an  error  to  ascribe  all  the  ill  feelings  that  accompany  it,  to  the 
fever  itself.  They  are  due  to  the  same  cause  that  produces  the 
rise  of  temperature. 

A  study  of  the  temperature  curve  in  its  relation  to  other  symp- 
toms will  give  one  a  fairly  accurate  picture  of  the  underlying 
pathology. 

Eise  of  temperature  in  tuberculosis  is  caused  by  bacillary 
toxins  and  by  the  tuberculous  process  per  se,  and  is  in  direct 
relationship  to  the  amount  of  pathological  change  present  and 


446 


SIGNS  AND  SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 


a!  to 


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FEVER  447 

the  toxins  absorbed,  on  the  one  hand,  and  the  ability  of  the  or- 
ganism to  maintain  its  physiological  heat  equilibrium  on  the 
other. 

Fever  is  not  important  in  advanced  tuberculosis  in  determin- 
ing the  presence  of  the  disease.  This  can  readily  be  determined 
by  other  symptoms  and  signs.  The  temperature  curve  is  of  great 
value,  however,  when  interpreted  in  conjunction  with  the  other 
symptoms  in  helping  the  clinician  to  form  an  opinion  of  the 
nature  of  the  pathological  changes  which  are  taking  place  in  the 
lung.  It  is  also  of  great  value  at  times  in  the  diagnosis  of  com- 
plications. 

The  appended  charts  show  the  common  curves  in  tuberculosis. 
Fig.  91  is  typical  of  chronic  fibroid  or  chronic  fibro-ulcerative  tu- 
berculosis during  the  period  of  quiescence.  Fig.  92  shows  the 
curve  of  the  same  type  of  disease  during  periods  of  slight  activ- 
ity. Fig.  93  shows  the  type  of  temperature  commonly  found 
when  the  process  becomes  markedly  active  and  is  accompanied 
by  extensive  necrosis,  and  caseation  and  an  extension  to  new  tis- 
sue. I  shall  not  attempt  to  illustrate  the  various  types  of  tem- 
perature more  fully  at  this  time,  but  leave  the  subject  for  a  more 
complete  consideration  elsewhere  in  these  pages  (see  Volume  II, 
Chapter  XXX. 

Hoarseness. — Hoarseness  may  be  due  to  several  causes  in  ad- 
vanced tuberculosis.  Probably  the  most  frequent  cause  operat- 
ing to  produce  it  is  reflex  stimulation.  This  we  are  justified  in 
assuming  from  the  fact  that  it  begins  often  as  one  of  the  earliest 
symptoms  before  other  causes  which  operate  later,  are  present, 
and  also  from  the  fact  that  it  is  so  often  exaggerated  with  the 
acute  inflammatory  changes  which  accompany  the  advanced  dis- 
ease. 

The  stimulation  may  come  through  either  the  superior  or  in- 
ferior laryngeal  nerves.  When  through  the  former,  there  is  a 
relaxed  condition  of  the  cords ;  they  are  not  stretched  tightly,  but 
have  a  sagging  appearance;  the  ends  approximate,  but  the 
centers  do  not,  leaving  an  oval  slit  between,  as  shown  in  Fig.  81. 
"When  through  the  inferior  laryngeal,  the  cord,  usually  on  one 
side,  lags,  failing  to  approximate  its  fellow,  as  shown  in  Fig.  82. 


448 


SIGNS  AND   SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 


FEVER    CHART 


449 


Eh 


,2Ja 


ft- 


450  SIGNS  AND  SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

While  the  form  of  nerve  reflex  coming  through  the  inferior  laryn- 
geal has  been  recognized  for  a  long  time,  I  find  it  present  as  a 
cause  of  hoarseness  probably  less  often  than  the  type  due  to  the 
superior  laryngeal  irritation.  It  is  better  known  because  we 
have  found  it  in  aneurisms  and  as  a  result  of  gland  pressure.  I 
am  sure,  however,  that  it  is  not  necessary  to  have  pressure  on 
the  recurrent  nerve  to  cause  it,  but  that  it  may  be  found  as  a  re- 
flex motor  disturbance  from  the  inflammation  in  the  lung. 

Hoarseness  may  also  be  due  to  a  simple  inflammation.  It  is 
important  to  bear  in  mind  that,  while  hoarseness  is  often  an  im- 
portant symptom  in  tuberculosis  of  the  larynx,  it  does  not  neces- 
sarily point  to  it.  The  constant  cough  in  advanced  cases  often 
causes  an  irritation  of  the  cords  which  results  in  hoarseness. 
Mucus  may  cover  them  and  produce  it.  And  we  must  not  for- 
get the  dragging  on  the  nerves  which  occurs  when  contractions 
take  place,  resulting  in  shifting  of  the  mediastinum.  We  often 
find  an  increased  hoarseness  at  this  time.  Complete  aphonia  is 
often  present  as  a  result  of  reflex  nerve  stimulation  during  acute 
caseation.    Acute  or  chronic  laryngitis  may  also  be  present. 

There  is  also  occasionally  found  a  reflex  inflammation 
(neuritis)  of  branches  of  the  laryngeal  nerves  which  accompanies 
and  results  from  advanced  tuberculous  inflammation  in  the  lungs. 
It  is  accompanied  by  pain  and  hoarseness.  It  may  persist  for  an 
indefinite  time ;  sometimes  only  a  few  days,  other  times  for  weeks. 
The  pain,  and  the  character  of  the  voice,  is  not  unlike  that  of 
tuberculous  laryngitis.  At  the  time  of  writing  this  I  have  three 
such  cases  under  observation.  All  have  had  tuberculous  ulcera- 
tion in  the  larynx  which  is  now  healed.  They  have  enjoyed  the 
full  use  of  their  voice  for  several  months ;  and,  on  laryngoscopic 
examination,  the  larynx  is  free  from  active  inflammation ;  yet,  the 
voice  is  extremely  hoarse,  and  the  patients  complain  of  pain 
running  up  into  the  ear,  much  the  same  as  when  open  ulceration 
is  present.  The  prognosis  is  good.  Why  this  should  be  pro- 
nounced in  some  cases  and  not  in  others,  cannot  be  satisfactorily 
explained  at  present. 

Tickling1  in  the  Larynx  and  Cough. — Tickling  in  the  larynx  is 
a  sensory  phenomenon  which  has  its  full  expression  in  cough. 


LARYNGEAL   IRRITATION  451 

It  may  be  reflex,  the  irritation  being  in  any  part  of  the  bronchial 
tubes  or  pleura,  or  it  may  be  due  to  local  irritation  from  foreign 
material  such  as  mucus;  or  from  an  inflammatory  process  af- 
fecting the  larynx  itself.  This  irritation  provokes  a  desire  to 
cough.  Whether  the  cough  shall  be  produced  or  not,  is  largely 
a  matter  of  will.  A  great  deal  of  coughing  in  tuberculosis  can 
be  avoided  if  only  the  patient  will  restrain  himself. 

Inflammation  of  the  pleura  is  nearly  always  accompanied  by  a 
dry,  unsatisfying  cough.  In  advanced  tuberculosis,  a  certain 
amount  of  cough  is  necessary  to  expel  the  mucus,  but  this  can 
be  reduced  to  a  very  small  amount,  compared  to  what  it  wo  aid 
be  if  the  patient  permitted  his  desires  to  go  unrestrained.  When 
mucus  is  found  in  the  bronchi  it  probably  does  not  produce  much 
irritation  until  it  gets  to  the  bifurcation  of  the  trachea.  This  is 
an  area  of  increased  sensibility.  Then,  after  passing  this  point, 
an  area  of  decreased  sensibility  is  again  found  until  the  larynx 
is  reached.  The  bifurcation  of  the  trachea  and  larynx  are  the 
two  danger  points  of  obstruction  and  nature  has  rightly  en- 
dowed them  with  an  increased  sensibility  so  that  foreign  ma- 
terial will  be  quickly  and  involuntarily  removed.  When  mucus 
reaches  these  points  the  desire  to  cough  is  increased. 

The  wall  of  cavities  is  comparatively  insensitive.  Large  ac- 
cumulations of  secretion  may  remain  within  them  without  pro- 
voking cough.  When  they  are  filled,  however,  and  overflow,  and 
the  secretion  begins  to  gain  access  to  the  bronchi,  cough  is  pro- 
voked; and,  when  the  points  of  special  sensitization  just  men- 
tioned are  reached,  the  desire  is  increased,  and  kept  up  until 
the  mucus  is  forced  on  beyond  and  in  the  latter  case  expelled. 
The  amount  of  necessary  cough  depends  considerably  upon  the 
amount  and  character  of  secretion;  and  this,  in  turn,  depends 
a  great  deal  on  the  amount  of  active  destruction  and  the  degree 
of  associated  bronchial  inflammation  present.  An  acute  cavity, 
which  has  just  formed,  produces  more  secretion  as  a  rule,  than  a 
chronic  one,  consequently  calls  for  more  cough.  When  cavities 
of  considerable  dimension  are  present  the  patient's  cough  is 
usually  exaggerated  on  change  of  posture.  On  awakening  and 
moving  in  the  morning  and  again  on  going  to  bed  at  night,  a 


452  SIGNS  AND  SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

paroxysm  of  cough  is  precipitated  which  does  not  cease  until  the 
cavities  are  emptied;  or,  at  least,  until  that  portion  of  the  se- 
cretion which  gains  access  to  the  bronchi  is  expelled. 

Changes  in  position  which  permit  of  the  escape  of  secretion 
into  the  air  passages  causes  cough.  Patients  learn  that  they  can 
lie  on  one  side  or  in  one  position  without  cough,  while  lying  on 
the  other  side,  or  in  another  position,  excites  it. 

While  a  certain  amount  of  cough  is  necessary,  and  unavoid- 
able, no  unnecessary  coughing  should  be  allowed  because  of  cer- 
tain deleterious  effects  which  follow  it.  It  is  an  explosive  ex- 
piratory act  begun  with  the  glottis  closed  when  the  pressure  in 
the  air  passages  is  high.  As  a  result  of  this  there  is  a  forcible 
dilatation  of  the  pulmonary  parenchyma,  which  has  a  tendency 
to  force  bacillus  bearing  mucus  into  the  small  bronchi,  favoring 
secondary  bronchogenic  infection.  It  also  causes  a  damming 
back  of  the  blood  into  the  systemic  veins.  Cough  and  deep 
breathing  are  probably  the  two  factors  which  are  responsible 
for  the  most  bronchogenic  infections.  Inasmuch  as  this  is  a  com- 
mon method  by  which  the  infection  spreads,  when  a  lung  is  once 
involved,  cough  and  deep  breathing  should  be  avoided  as  much 
as  possible. 

Chest  Pains. — The  classification  and  differentiation  of  pain  in 
and  about  the  chest  is  attended  by  great  difficulty.  The  patient 
with  chest  pains  is  usually  frightened  and  more  or  less  certain 
that  serious  pulmonary  disease  is  present.  The  symptom  "pain" 
will  cause  the  patient  to  consult  a  physician  more  quickly  than 
any  other.  This  being  true,  it  is  unfortunate  that  tuberculosis 
is  not  always  accompanied  by  pain;  but  it  is  the  duty  of  the 
physician  to  familiarize  himself  with  the  pains  in  the  chest  so 
that  he  may  be  able  to  assign  to  them  their  proper  significance. 

The  pains  which  must  be  considered  and  differentiated  in  chest 
diseases  are  those  due  to  intrathoracic  organs  and  those  due  to 
intra-abdominal  organs  but  which  express  themselves  over  the 
same  or  adjacent  surface  areas. 

Pain  due  to  inflammation  of  the  lungs  and  pleura  may  be 
located  over  the  anterior  or  posterior  portion  of  the  thoracic  wall, 
in  or  over  the  shoulders,  and  in  or  over  the  abdominal  wall. 


pain  453 

Pain  of  thoracic  origin  may  be  due  to  diseases  of  the  soft  parts, 
the  nerves,  the  bones,  pleura,  lungs,  heart,  pericardium,  blood 
vessels,  or  mediastinal  glands.  Those  with  which  we  are  particu- 
larly interested  are  those  from  the  inflammation  in  the  pleura, 
lungs,  and  mediastinal  glands. 

Nearly  all  patients  experience  some  pain  during  the  course 
of  tuberculosis,  although  it  is  usually  interrupted  in  character 
and  of  short  duration.  The  reflex  pains,  particularly  those  which 
are  due  to  reflex  neuritis,  and  those  of  pleural  origin,  more 
particularly  those  due  to  adhesions  in  which  the  pleural  and  in- 
tercostal nerves  become  involved  in  the  inflammation,  come  and 
go  with  atmospheric  and  meterologic  changes.  The  same  is  true 
of  the  reflex  pains  noted  in  the  sensory  zones  of  the  skin.  When 
weather  changes  are  most  pronounced  these  pains  are  most  an- 
noying. 

When  acute  cavity  formation  is  in  progress  the  patient  will 
often  locate  the  point  of  inflammation  quite  accurately  by  the 
pain  experienced.  Occasionally  he  may  also  suspect  an  ap- 
proaching hemorrhage  by  a  discomfort  or  pain  which  he  has 
learned  to  associate  with  it.  This  is  probably  the  more  accurate 
the  nearer  it  is  to  the  pleural  surfaces. 

During  the  compensatory  changes  which  take  place  when 
marked  contraction  affects  one  lung  and  a  compensatory  em- 
physema takes  place  in  the  other,  adhesions  are  often  stretched 
and  torn  with  a  resultant  discomfort  or  pain.  Sometimes  the  pain 
is  quite  acute.  At  times  there  may  be  no  actual  pain  noted,  yet 
the  pullings  and  drawing  may  be  sufficient  to  cause  great  dis- 
comfort, the  patient  complaining  of  a  feeling  of  tightness  or 
compression. 

The  pain  resulting  from  coughing,  particularly  during  the 
time  of  acute  process,  when  the  cough  is  greatly  increased,  is  felt 
at  the  attachment  of  the  abdominal  muscles  along  the  costal 
arch,  and  is  often  very  disturbing  to  the  patient  causing  him  to 
think  a  very  severe  inflammation  is  underlying  it. 

Our  knowledge  of  the  reflex  sensory  disturbances  which  mani- 
fest themselves  as  areas  of  hyperesthesia  and  hyperalgesia  of  the 
skin  when  the  abdominal  and  thoracic  organs  are  inflamed  is 


454  SIGNS   AND   SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

largely  due  to  the  work  of  James  Ross,2  Head3  and  James 
Mackenzie.4     These  original  contributions  repay  careful  study. 

The  sympathetic  nerves*,  which  come  from  inflamed  organs 
such  as  the  lungs,  when  the  seat  of  tuberculosis,  or  any  other 
inflammation,  carry  impulses  through  the  rami  communicantes  to 
the  gray  substance  of  the  spinal  cord  and  there  set  up  in  the 
cells  a  state  of  increased  irritability.  Sensory  nerves  which  take 
their  origin  from  the  cells  in  the  same  segments  of  the  cord  which 
are  thus  irritated  by  the  sympathetic,  are  so  influenced  that  their 
impressions  are  heightened.  Thus,  the  skin  supplied  by  them 
may  become  more  sensitive  than  normal  to  such  stimuli  as  heat, 
cold  and  touch.  Painful  sensations  are  out  of  proportion  to 
their  severity. 

The  areas  of  the  skin  which  show  sensory  changes  in  inflam- 
mation in  the  lung  are  those  which  are  innervated  by  the  third 
and  fourth  cervical  and  first  to  sixth  dorsal  segments,  although 
the  third  and  fourth  cervical  and  third,  fourth,  and  fifth  dorsal 
zones  or  segments  are  the  ones  in  which  most  of  the  pain  from  the 
lungs  is  reflected.  These  zones  may  be  seen  in  Figs.  27  and  28, 
pages  182  and  183. 

These  sensory  changes  are  not  present  at  all  times  during  the 
course  of  pulmonary  tuberculosis.  They  are  most  commonly 
found  in  early  lesions,  and  at  times  of  acute  activity  in  the 
process.  |     ;:  ■  <  ■  '':' f"  f\  fjl| 

Not  only  are  there  sensory  changes  but  motor  changes  also, 
which  are  entirely  analogous  in  their  causation  and  distribution, 
as  I  have  shown  previously  and  as  described  in  Chapter  VI.  Re- 
sulting from  the  prolonged  irritation  of  the  cells  which  give 
origin  to  the  motor  filaments  they  become  inflamed;  and  this  ir- 
ritation, at  times,  shows  in  the  nerve  as  a  true  neuritis,  usually, 
however,  of  only  moderate  degree  of  severity.  This  is  further 
favored  by  the  toxemia  present;  but  since  it  is  so  often  present 
early,  before  toxemia  becomes  so  prominent  a  factor,  and,  since 
it  is  regional,  showing  only  on  the  affected  side  and  in  definite 
areas;  I  feel  that  we  are  wholly  justified  in  considering  this 


20n  Segmental   Distribution   of  Sensory  Disorders,   Brain,    1888. 
8Brain,  vol.  xvi,  1893.  .    „,        .  , 

"Sensory    Symptoms    Associated    With   Visceral    Disease,    Medical    Chronicles,    vol.    xvi, 
1892;  and  Symptoms  and  Their  Interpretation,  London,   1909. 


pain  455 

type  of  pain  as  due  to  localized  neuritis  caused  reflexly  through 
the  sympathetic  irritation  of  the  cells  which  give  origin  to  the 
motor  filaments.  Thus  do  we  account  for  many  of  the  aching 
pains  in  the  shoulders,  which  are  so  commonly  called  rheuma- 
tism. Rheumatism  of  the  shoulder,  particularly  if  confined  to 
one  side  and  if  in  an  individual  who  is  below  par  physically, 
should  cause  the  examiner  to  give  attention  to  the  underlying 
lung. 

Pains  caused  by  pleurisy  show  a  varied  distribution  (see 
Volume  II,  Chapter  XXV.  Not  only  may  the  pain  be  over  the 
seat  of  inflammation,  but  it  may  extend  beyond  the  area,  and 
even  be  transferred  to  other  nerves.  Thus,  diaphragmatic 
pleurisy  may  show  pain  and  spasm  over  the  abdominal  wall 
through  the  tenth,  eleventh  and  twelfth  thoracic  nerves  or 
over  the  shoulder,  the  impulse  being  carried  by  the  phrenics  to 
the  third  and  fourth  cervical  segments  where  the  reflex  is  trans- 
ferred to  the  external  supraclavicular  nerve  derived  from  the 
third  and  fourth  cervicals.  This  shoulder  pain  is  a  developmental 
remnant  and  due  to  the  fact  that  in  earlier  life  the  diaphragm  is 
on  a  level  with  these  cervical  segments. 

The  pain  and  spasm  of  the  abdominal  muscles,  due  to  di- 
aphragmatic pleurisy  is,  at  times,  mistaken  for  inflammation  be- 
low the  diaphragm,  and  operation  has  been  undertaken  because 
of  it. 

Intercostal  neuralgia  is  a  diagnosis  often  made;  but  like  "la 
grippe"  and  "neurasthenia"  the  diagnosis  so  often  means  noth- 
ing. The  cause  of  neuralgia  is  the  important  thing.  Very  often 
the  diagnosis  of  tuberculous  pleurisy  would  be  the  correct  one 
instead. 

Pain  over  the  sternum  may  be  caused  by  bronchitis,  media- 
stinitis,  aneurism,  hyperchlorhydria,  or  disease  of  the  sternum 
itself. 

Pain  over  the  right  shoulder  is  often  caused  by  gall  bladder 
disease,  while  that  over  the  left  may  be  due  to  affections  of  the 
stomach  or  colon. 

Pain  over  the  left  mammary  region,  radiating  down  the  in- 
side of  the  left  arm  is  usually  of  cardiac  origin.    It  accompanies 


456  SIGNS   AND   SYMPTOMS   OF   PULMONARY   TUBERCULOSIS 

myocardial  degeneration  and  dilatation  in  advanced  tuberculosis 
also  pulmonary  inflammation  near  the  heart. 

In  uterine  and  ovarian  diseases  pain  may  be  found  in  the  breast 
at  the  time  of  menstruation.  This  is  commonly  found  in  tuber- 
culosis, but  whether  there  is  any  relation  between  it  and  the 
tuberculosis  I  have  never  been  able  to  determine. 

Pain  in  the  back  over  the  interscapular  region,  high  up,  may  be 
due  to  pericarditis,  disease  of  the  lungs,  diaphragmatic  pleurisy 
and  aortic  lesions.  Pain  in  the  areas  immediately  below  this  is 
usually  due  to  mediastinal  affections.  Pain  near  the  spine,  with- 
in the  angle  of  the  scapula  on  the  left  may  be  due  to  the  stomach, 
and  on  the  right,  at  the  angle  may  be  due  to  the  liver,  while  pain 
in  the  scapular  region  is  usually  due  to  the  lungs.  The  pain 
experienced  in  the  lower  part  of  the  chest  along  the  attachment 
of  the  diaphragm  in  cases  of  colitis  or  stomach  affections  ac- 
companied by  much  gas,  are  often  very  distressing  to  the  mind 
of  the  patient  and  usually  considered  by  him  to  mean  serious 
pulmonary  trouble.  It  is  necessary  to  bear  these  pains,  which 
are  over  chest  areas,  but  due  to  other  organs,  in  mind  for  dif- 
ferential diagnosis. 

Symptoms  on  the  Part  of  the  Nervous  System. — The  symptoms 
which  arise  on  the  part  of  the  nervous  system  in  advanced  tuber- 
culosis are  many  and  varied  in  character.  For  their  discussion  see 
Chapters  VI,  VII  and  VIII.  One  cannot  understand  tuberculosis 
and  the  disturbed  functions  accompanying  it  without  understand- 
ing the  nervous  system. 

Acidosis. — There  are  probably  many  factors  present  in  tu- 
berculosis which  have  a  tendency  to  increase  acidosis,  such  as  de- 
ficient intake  of  oxygen;  deficient  excretion  of  carbon  dioxide 
which  occurs  particularly  late  in  the  disease  as  a  result  of  di- 
minished pulmonary  area;  slowness  of  the  circulation  owing  to 
the  peculiar  vasomotor  changes;  also  the  general  changes  in  the 
tissues  themselves,  and  disturbance  on  the  part  of  the  heart. 
Toxins  also  probably  act  to  the  same  end.  This  may  be  the 
ultimate  explanation  of  the  dyspnea  which  appears  when  the 
body  is  called  upon  for  extra  exertion. 

This  subject  has  received  a  great  deal  of  attention  recently, 
particularly  by  men  who  are  interested  in  diseases  of  the  heart 


DYSPNEA  457 

and  kidney,  but  it  also  demands  attention  from  those  who  are 
interested  in  pulmonary  troubles. 

Dyspnea. — Dyspnea  is  a  symptom  which  arises  in  advanced 
tuberculosis  under  several  different  conditions.  At  times  it  comes 
on  early  in  the  disease.  It  is  an  indication  of  either  a  difficulty 
or  an  inability  of  the  respiratory  system  to  adjust  itself  and 
properly  oxygenate  the  blood  under  the  unnatural  conditions 
under  which  it  is  working,  from  which  there  is  an  increased  acidosis 
resulting  in  dyspnea  as  just  mentioned. 

Eespiratory  movements  are  for  the  sole  purpose  of  keeping 
up  the  proper  gaseous  exchange  between  the  body  tissues  and 
the  atmosphere.  Interference  with  this  exchange  may  result 
from  disturbances  of  the  respiratory  tissues  themselves,  such  as 
comes  in  tuberculosis  and  other  causes  which  interfere  with  the 
proper  propulsion  of  the  blood  through  the  body. 

When  the  disease  is  active  and  spreading  rapidly  it  is  im- 
possible for  the  remaining  portions  of  the  lung  to  compensate 
with  sufficient  rapidity  to  avoid  dyspnea  even  though  the  loss  of 
tissue  of  itself  is  not  sufficient  to  warrant  the  degree  of  disturb- 
ance noted.  Part  of  the  disturbance  under  such  circumstances 
is  undoubtedly  due  to  the  severe  toxemia  present,  and  is  of 
nervous  origin. 

The  most  severe  dyspnea  that  I  have  met  in  this  disease  is  in 
chronic  fibroid  tuberculosis,  when  the  process  has  gradually  ex- 
tended until  it  has  completely  used  up  all  reserve  lung  tissue. 
Such  cases,  as  a  rule,  have  not  only  insufficient  pulmonary  tissue 
to  aerate  the  blood,  but  they  also  have  a  weakened  heart  muscle, 
an  altered  blood  supply,  and,  as  a  rule,  pleural  adhesions  of  such 
density  as  to  greatly  interfere  with  the  respiratory  act  and  to 
cause  the  weakened  compensatory  respiratory  muscles  to  be 
called  into  operation. 

Dyspnea  is  increased  on  exertion.  A  patient  may  be  perfect- 
ly comfortable  while  resting  and  yet  be  unable  to  measure  up  to 
the  least  extra  exertion  without  showing  dyspnea. 

Coughing  is  often  sufficient  to  bring  on  such  a  degree  of 
dyspnea  that  the  patient  fears  for  repetition  of  the  paroxysm. 

Best  is  the  first  and  most  important  measure  for  the  relief  of 


458  SIGNS  AND  SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

dyspnea.  But  measures  which  will  benefit  either  the  heart,  the 
condition  of  the  blood,  or  remove  pathological  changes  from  the 
lung,  will  prove  helpful.  Sometimes  it  is  exaggerated  by  dis- 
turbances in  the  gastrointestinal  tract,  and  can  be  relieved  by 
attention  to  conditions  below  the  diaphragm. 

Not  only  the  degree  of  embarrassment,  but  the  cause  of  it 
must  be  taken  into  consideration  in  the  prognosis. 

Hectic  Flush. — Hectic  flush  is  a  reflex  symptom  confined,  for 
the  most  part,  to  the  periods  when  the  tuberculosis  is  active.  It 
often  comes  on  early  and  is  found  in  all  stages  of  the  disease. 
The  flush  is  a  reflex  dilatation  of  the  blood  vessels  of  the  face, 
head,  and  ear.  It  is  confined  to  the  side  of  activity  when  unilat- 
eral and  more  marked  on  the  side  of  greatest  activity  when  bilat- 
eral (see  page  199).  The  irritation  which  dilates  the  vessels  of 
the  face  and  head  passes  through  the  superior  cervical  ganglion 
coming  from  the  second  and  fourth  thoracic  filaments  of  the  sym- 
pathetic; and  from  the  third  cervical  nerve. 

Sputum. — Sputum  is  sometimes  present  very  early  and  is  near- 
ly always  an  accompaniment  of  an  advanced  process.  There  may 
be  a  slight  amount  of  secretion  present  as  a  result  of  exudation 
into  the  pulmonary  tissues  even  before  ulceration  occurs.  This 
early  secretion  may  be  mucoid  or  it  may  be  slightly  purulent 
in  character.  When  it  is  a  part  of  the  tuberculous  process  it  may 
show  a  high  lymphocyte  count  and  have  diagnostic  value,  even 
though  free  from  bacilli  (see  page  536).  Sputum  is  an  im- 
portant diagnostic  sign  for  it  is  due  to  the  tuberculous  process 
per  se.  For  a  critical  discussion  of  methods  of  examination  of 
sputum  and  the  interpretation  of  the  findings,  see  Chapter  XX, 
page  533. 

No  matter  how  insignificant  the  amount  of  sputum,  it  should 
be  collected  and  examined.  Much  time  will  be  saved  by  taking  a 
twenty-four  hour,  or  three-day  specimen,  when  the  amount  of  ex- 
pectoration is  slight,  as  it  sometimes  is  even  in  advanced  tubercu- 
losis. This  should  be  fermented  and  homogenized  by  a  shaking 
machine  or  treated  with  antiformin  before  examination,  as  de- 
scribed in  Chapter  XX. 

Sometimes  patients   claim  that  they  do  not  expectorate,   al- 


sputum  459 

though  physical  examination  indicates  the  presence  of  secre- 
tion. In  such  cases  the  sputum  is  sometimes  raised  into  the 
throat  and  swallowed.  In  a  few  such  cases  we  have  found  bacilli 
in  the  feces  when  we  were  unable  to  obtain  a  sample  of  sputum 
until  we  had  convinced  the  patients  of  what  they  were  doing. 

Chronic  fibroid  tuberculosis  may  be  extensive  and  yet  pro- 
duce little  or  no  expectoration.  The  ulcerative  type,  however, 
shows  varying  quantities,  usually  large  when  the  destructive 
process  is  acute  and  extensive. 

Not  all  secretions  expelled  by  the  tuberculous  patient  are  from 
the  ulcers  in  the  lung.  Much  of  it  is  of  bronchial  origin,  while 
some  patients  discharge  large  quantities  from  the  throat  and 
pharynx.  Some  patients  with  an  acute  destructive  process  in  the 
larynx  are  greatly  annoyed  by  profuse  secretion. 

Not  only  does  the  amount  of  secretion  vary  according  to  the 
involvement  in  the  lung  and  the  amount  of  bronchial,  laryngeal, 
and  pharyngeal  irritation  present,  but  it  varies  greatly  according 
to  the  weather  changes  as  is  easily  explained.  When  the  air 
leaves  the  lungs  it  comes  out  saturated  with  moisture;  so  if  a 
dry  air  is  inhaled  it  will  carry  off  far  more  secretion  than  a 
moist  air  and  consequently  leave  less  to  be  expectorated.  In  this 
way  dry  atmospheres  of  favored  regions  help  to  reduce  the 
amount  of  secretion  expectorated. 

Whether  the  secretion  is  coming  from  cavities  or  from 
bronchial  inflammation  may  be  determined  somewhat  by  its  re- 
lationship to  posture.  If  it  is  from  a  cavity  it  may  accumulate 
as  long  as  the  position  is  such  that  the  opening  does  not  offer 
drainage;  but,  when  the  cavity  is  filled  or  when  the  posture  is 
changed  so  as  to  favor  drainage,  the  contents  are  usually  emp- 
tied. Under  these  conditions,  the  patient,  as  a  rule,  has  a  more 
or  less  severe  coughing  spell  on  arising  and  again  on  retiring. 
Patients  learn  that  there  are  certain  postures  which  favor  reten- 
tion and  assume  these  during  sleep,  otherwise  they  are  obliged 
to  cough  during  the  night.  Bronchial  secretion,  or  secretion 
from  small  cavities,  or  from  larger  ones  where  the  opening  favors 
drainage,  is  apt  to  be  expelled  as  it  forms,  during  the  day. 

The  origin  of  sputum  cannot  be  told  by  its  physical  character- 


460  SIGNS  AND   SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

istics.  The  appearance  of  cavity  sputum  may  be  the  same  as  that 
of  bronchial  origin;  so  may  its  consistency  be  the  same.  Some- 
times, however,  the  typical  nummular  sputa  are  present,  indicat- 
ing that  they  come  from  cavities. 

The  amount  of  sputum  varies  greatly.  It  may  be  only  a  few 
cubic  centimeters  or  it  may  be  five  or  six  ounces  in  twenty-four 
hours.  I  have  seen  as  much  as  750  cubic  centimeters  in  a  day. 
Large  quantities  may  come  from  chronic  non-tuberculous 
bronchitis;  but,  as  a  rule,  if  15  or  20  cubic  centimeters  are  ex- 
pectorated daily,  the  largest  portion  of  it  coming  in  the  early 
morning  on  arising,  a  cavity  should  be  suspected. 

Pleurisy. — Pleuritic  pain  is  a  common  symptom  in  advanced 
tuberculosis.  Its  diagnostic  value  should  always  be  recognized. 
There  is  no  excuse  for  allowing  the  diagnosis  to  go  unmade  when 
the  patient  suffers  from  this  symptom.  It  is  not  sufficiently  rec- 
ognized that  pleural  pain  may  have  many  characteristics  and  may 
be  located  in  various  parts  of  the  thorax.  Too  often  it  is  looked 
for  only  at  the  bases;  and  it  is  too  often  considered  to  be  only 
of  the  sharp  cutting  variety.  It  may  or  may  not  be  accompanied 
by  a  pleuritic  rub. 

The  pain  caused  by  pleurisy  may  be  sharp,  cutting,  stabbing, 
dull  and  aching,  or  boring;  in  fact,  it  may  have  almost  any  char- 
acteristic experienced  in  pain. 

Pleurisy  may  be  dry  or  accompanied  by  effusion.  The  most 
common  is  the  dry  variety.  Pleural  adhesions  are  the  result  of 
inflammation  of  the  pleura  and  are  present  to  some  extent  in 
nearly  every  case  of  advanced  tuberculosis.  Sometimes  they  are 
extremely  dense,  and  yet  the  patient  is  unable  to  give  a  history 
of  when  the  inflammation  occurred,  because  of  a  complete  absence 
of  pain.  (For  a  more  complete  description  see  Volume  II,  Chap- 
ter XXV.) 

Frequent  and  Protracted  Colds. — Many  advanced  cases  will 
give  a  history  of  repeated  colds  which  end  in  bronchitis  and  a 
persistent  cough.  All  such  are  suspicious.  Most  affections  of 
this  class  are  not  simple  bronchial  infections,  but  accompany 
periods  of  activity  in  the  tuberculous  involvement  in  the  lung 
and  should  be  investigated  carefully.  It  is  not  natural  for  man 
to  suffer  from  one  chest  cold  after  another.     Even  though  one 


HEMOPTYSIS  461 

was  specially  susceptible,  he  could  hardly  expect  to  have  fre- 
quent attacks  of  simple  bronchitis.  Therefore,  every  case  of  this 
kind  should  be  investigated  for  other  symptoms  of  tuberculosis, 
for  this  is  nearly  always  the  real  cause  of  the  symptoms.  The 
tuberculous  nature  of  the  affection  should  be  especially  suspected 
if  symptoms  of  toxemia  are  present. 

Hemoptysis. — Spitting  of  blood  is  most  commonly  due  to  a 
tuberculous  process.  It  assumes  many  forms.  It  may  be  slight 
in  amount  or  profuse.  It  may  be  bright  red,  pinkish,  or  dark 
colored.  Sometimes  blood  is  expectorated  from  the  gums  and 
occasionally  from  a  discharging  sinus.  Such  blood  is  usually 
small  in  amount  and  pinkish  in  character.  That  from  the  gums 
is  thin,  while  that  from  a  sinus  is  apt  to  be  mixed  with  the  thick 
mucus  of  the  throat.  Pinkish  blood  also  comes  from  cavities 
in  advanced  tuberculosis.  It  can  be  differentiated  from  that 
from  the  gums  by  its  consistency  and  from  that  from  the  sinuses 
by  the  fact  that  it  is  coughed  up  and  is  mixed  with  the  usual 
cavity  sputum  which  the  patient  is  accustomed  to  raise. 

Bright  blood  comes  not  only  from  tuberculous  lesions,  but 
small  amounts  may  come  from  infarct,  heart  disease,  trauma,  or 
pneumonia.  The  differential  diagnosis  should  not  be  difficult 
in  advanced  tuberculosis,  however,  for  other  symptoms  are  al- 
ways present. 

Profuse  hemorrhages  are  not  to  be  mistaken,  although  some 
men  persist  in  assuring  their  patients  that  they  are  from  the 
stomach. 

Tuberculous  women  often  expectorate  blood  at  the  time  of 
menstruation. 

As  diagnostic  signs,  bloody  expectoration  should  be  sufficient 
for  a  diagnosis  of  tuberculosis  in  late,  the  same  as  in  early  tuber- 
culosis, unless  definite  signs  of  other  causes  are  evident.  (For  fur- 
ther description  of  hemoptysis  see  Volume  II,  Chapter  XXXIII.) 

Menstruation. — In  advanced  tuberculosis  the  menstrual  func- 
tion is  greatly  disturbed.  It  is  accompanied  by  many  symptoms 
on  the  part  of  other  organs  and  an  exaggeration  of  already  ex- 
isting symptoms.  When  the  drain  upon  the  patient's  strength 
becomes  marked  as  a  result  of  combating  the  active  disease, 
especially  during  the  periods  of  caseation  with  its  attendant  loss 


462  SIGNS  AND  SYMPTOMS   OF  PULMONARY   TUBERCULOSIS 

of  strength,  the  menstrual  function  often  becomes  irregular  and 
not  infrequently  ceases.  Formerly  this  was  looked  upon  as  a  con- 
dition leading  to  tuberculosis.  It  was  common  report  "that  the 
patient's  menstruation  stopped  and  that  threw  her  into  con- 
sumption." This  is  still  believed  by  many;  although  a  little  at- 
tention given  to  the  clinical  history  will  always  reveal  the  pres- 
ence of  other  symptoms  of  tuberculosis  prior  to  the  cessation  of 
the  menstrual  flow.  Before  the  flow  ceases  and  where  it  does 
not  stop  entirely  it  often  becomes  scanty  and  of  shorter  duration. 

Measures  directed  to  the  generative  organs  should  not  be  em- 
ployed to  reestablish  the  flow.  Nature  stops  it  in  order  to  re- 
lieve the  drain.  When  the  cause  which  made  the  cessation  desir- 
able has  disappeared,  and  the  patient  has  regained  sufficient 
strength  the  flow  reestablishes  itself  coincident  with  the  general 
improvement.  I  have  seen  the  flow  reestablished  after  being  ab- 
sent a  year  or  more. 

Occasionally  the  flow  does  not  reestablish,  but  a  premature 
menopause  comes  on.  I  have  seen  this  a  few  times  in  patients 
in  the  late  thirties  and  early  forties,  even  though  a  reasonable 
degree  of  health  had  been  attained. 

Aside  from  the  disturbances  in  function  just  described  as  being 
due  to  the  low  tone  of  the  patient,  all  other  menstrual  disorders 
which  affect  women  are  encountered  and  must  be  dealt  with. 

The  menstrual  period  seems  to  be  the  time  when  women  are 
less  resistant  to  disease.  That  it  is  a  time  of  great  nervous  ten- 
sion is  well  known.  The  nervous  explosions  which  precede  and 
accompany  it  should  be  anticipated.  The  physician  who  observes 
his  patients  closely  will  often  be  able  to  relieve  a  high  nervous 
tension,  remove  fears  and  depression,  cut  short  what  would  other- 
wise be  a  spell  of  distrust  or  lack  of  confidence,  or  even  anger  or 
rage,  by  explaining  to  the  patient  that  it  is  only  the  nervous 
tension  preceding  the  menstrual  period.  Quiet  patients  often 
become  hard  to  please,  quarrelsome  and  faultfinding  at  this  time. 
The  whole  world  seems  to  be  working  against  them.  They  feel 
unhappy  and  entertain  great  fears  of  their  recovery  and  often 
become  extremely  pessimistic  as  to  the  cure  of  tuberculosis  in 
general.  Difficulty  of  sleeping  is  common.  This  is  the  time  when 
a  word  of  discouragement  will  be  magnified  many-fold  and  unless 


MENSTRUATION  463 

counteracted  may  lead  the  patient  to  give  up  hope  of  cure.  The 
physician  must  anticipate  these  nervous  manifestations  and  ex- 
plain them  to  the  patient.  It  might  be  thought  that  once  telling 
is  sufficient  but  that  is  not  so.  It  is  forgotten  as  soon  as  the 
symptoms  pass  away  and  it  will  be  necessary  to  repeat  the  same 
assurances  the  next  time,  and  the  next.  Gentle  reason  will 
nearly  always  be  appreciated  by  the  patient. 

An  exaggeration  of  symptoms  is  also  common  at  this  time. 
The  normal  premenstrual  disturbance  in  temperature  sometimes 
assumes  an  acute  type,  a  rise  of  one  or  several  degrees  taking 
place;  tuberculous  masses  are  apt  to  caseate,  and  cough  and  ex- 
pectoration increase.  If  the  patient  is  suffering  from  diarrhea 
it  is  apt  to  be  worse;  if  constipation  is  present  it  is  often  more 
obstinate.  For  a  more  complete  discussion  of  the  physiological 
characteristics  of  the  menstrual  cycle,  see  page  195. 


CHAPTER  XVII. 

THE  PHYSICAL  EXAMINATION  OF  THE  PATIENT  IN 
ADVANCED  PULMONARY  TUBERCULOSIS. 

The  general  rules  for  the  examination  of  the  patient,  as  laid 
down  in  connection  with  early  tuberculosis  in  Chapter  XV  should 
be  followed. 

INSPECTION. 

Recalling  our  general  remarks,  inspection  can  be  carried  out 
much  more  efficaciously  when  the  patient  is  sitting  than  when  ly- 
ing. This  is  not  only  because  of  better  distribution  of  light,  but 
because  the  respiratory  act  can  be  better  studied.  It  is  easier 
to  study  the  respiratory  movements  of  the  lower  portions  of  the 
chest  when  the  patient  is  seated  higher  than  the  examiner,  and 
as  this  is  valuable  in  determining  the  diaphragm  reflex  in  early 
tuberculosis  and  the  compensatory  changes  in  advanced  tubercu- 
losis, I  prefer  such  a  position. 

Ideal  conditions  for  inspection  are  a  warm  room,  a  revolving 
stool  for  each  the  patient  and  examiner;  the  patient  stripped  to 
the  waist;  the  waist  band  loosened;  and  a  strong  light,  prefer- 
ably daylight,  shining  directly  on  the  patient  from  the  front. 

Inspection  alone,  if  sufficiently  searchingly  carried  out,  will 
give  the  examiner  a  fair  idea  of  the  pathological  changes  which 
have  taken  place  within  the  chest  and  of  the  effect  of  such 
changes  on  the  patient.  In  most  cases  it  is  possible  by  studying 
the  effects  of  the  motor  and  trophic  reflexes  on  the  muscles  and 
subcutaneous  tissues,  the  movements  of  the  chest  wall,  the  flat- 
tenings  and  bulgings  of  the  bony  thorax  when  these  are  pres- 
ent, and  the  position  of  the  heart  beat,  to  determine  with  sur- 
prising accuracy  the  nature  and  extent  of  the  pathological 
changes  within.  Inspection  reveals  more  in  advanced  tubercu- 
losis than  in  early. 

Inspection  calls  for  the  closest  powers  of  observation  and  the 


INSPECTION 


465 


keenest  analysis  of  data.  It  is  not  only  necessary  to  note  de- 
partures from  the  normal,  but  such,  departures  must  be  assigned 
to  their  cause.  They  must  be  dealt  with  as  being  expressions  of 
definite  pathological  changes.  The  skin  should  be  inspected, 
noting  cyanosis,  edema,  enlarged  vessels,  atrophies  or  any  other 
departure  from  the  normal.  Any  enlargement  of  the  lymphatic 
glands  or  the  thyroid  should  be  noted. 

Atrophy  and  lower  position  of  the  breast  upon  the  thorax  is 
often  to  be  seen  on  the  affected  side. 


a  b  c 

Fig.   94. — Phthisical  chest.  A,   anterior  view;  B,  lateral  view;   C,   posterior  view. 


The  form  of  the  chest  should  be  observed.  Much  has  been  writ- 
ten about  the  phthisical  chest  (Fig.  94,  A,  B,  C)  which  is  char- 
acterized as  being  long,  flattened,  particularly  above,  with  acute 
costal  angle,  winged  scapulas,  wide  intercostal  spaces,  cupped 
supraclavicular  fossaa,  a  drooping  forward  of  the  shoulders  and 
a  poorly  developed  musculature.  This  type  of  chest  has  been 
handed  down  through  the  ages  as  belonging  to  a  group  of  in- 
dividuals which  is  specially  predisposed  to  tuberculosis.  Some  of 
these  characteristics  belong  to  two  different  conditions,  the  so- 
called  plitJiisicus  habitus  and  asthenia  congenita  universalis. 
Phthisicus  habitus  must  be  looked  upon  as  being  a  result  of  tubercu- 


466        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

lous  infection,  instead  of  a  predisposing  cause,  while  asthenia 
congenita  universalis  with  its  long  chest,  wide  intercostal  spaces, 
acute  costal  angle  and  poorly  developed  musculature  is  an  expres- 
sion of  congenital  weakness.  Such  patients  sometimes  develop  tu- 
berculosis the  same  as  those  of  robust  build,  but  it  is  questionable 
whether  this  type  of  individual  furnishes  more  than  its  due  pro- 
portion of  tuberculous  infection. 

Reflex  Spasm  and  Degeneration  of  Muscles,  Subcutaneous 
Tissue  and  Skin. — The  condition  of  the  muscles  and  subcutaneous 
tissue  of  the  advanced  tuberculous  patient  is  important  in  diag- 
nosis. 

Varying  degrees  of  spasm  of  the  muscles  exist  and  varying 
degrees  of  atrophy  of  all  the  soft  parts,  including  the  skin,  sub- 
cutaneous tissue  and  muscles  take  place  according  to  the  under- 
lying pathological  changes. 

Spasm  or  increased  tone  in  the  muscles  of  the  neck,  particularly 
the  sternocleidomastoideus,  scaleni,  trapezius,  and  levator  anguli 
scapulae  as  it  appears  in  advanced  tuberculosis,  is  nearly  always 
a  regional  reflex  expression  of  active  inflammation  in  the  un- 
derlying lung.  Where  one  lung,  however,  has  undergone  marked 
destruction  and  contraction,  and  the  other  has  taken  upon  itself 
a  high  degree  of  emphysema,  the  accessory  muscles  of  respira- 
tion, particularly  the  sternocleidomastoideus  and  scaleni  may 
show  increased  tone  because  of  the  extra  work  thrown  upon 
them.  Extremely  rarely  this  may  cause  some  confusion  in  that 
the  increased  tone  is  taken  as  indicating  inflammation  of  the  un- 
derlying apex.  Careful  analysis  of  all  conditions  present  will 
usually  make  the  diagnosis  plain.  Atrophy  of  the  soft  parts, 
regional  in  character,  must  be  looked  upon  as  being  expressive 
of  a  chronic,  or  it  may  be  healed,  inflammatory  process  in  the 
underlying  lung.  It  may  also  be  due  to  occupational  change  in 
the  muscles;  and  at  the  time  of  observation  may  be  caused  by 
a  general  wasting.  Close  observation  will  usually  reveal  the 
nature  of  the  atrophy,  whether  regional  or  general. 

Regional  atrophy  is  most  easily  observed  in  the  tissues  of  the 
supraclavicular  notch  and  those  between  the  nipple  and  the 
clavicle,  anteriorly ;  and  the  tissues  above  the  spine  of  the  scapula 
running  up  on  the  neck,  and  those  of  the  interscapular  region 


"'■ 


Fig.  95^.— Illustrating  marked  regional  degeneration  of  the  muscles  and  other  soft 
tissues  over  the  anterior  surface  of  the  chest  as  a  result  of  chronic  tuberculo  is  The 
esion  is  older  and  more  extensive  on  the  right  side.  The  degeneration  of  the  soft 
tissues  on  the  right  ,s  particularly  marked.  The  lowering  of  the  angle  of  the  trapezius 
is  well  shown  both  anteriorly  and  posteriorly;  so  is  the  degeneration  of  the  r  ght  sLrno 
cleidomastoideus  as   compared  with  the  left.  g       sterno 


Fig.  95B. — Same  as  Fig.  95A,  showing  posterior  view.  The  right  trapezius  and  other 
soft  tissues  are  wasted  more  than  those  on  the  left  and  permit  the  shoulder  to  drop 
markedly. 


CHANGES  IN  SOFT   TISSUES  467 

posteriorly  (Fig.  95,  A  and  B).  While  other  portions  of  the 
chest's  coverings  show  reflex  atrophy  at  times,  these  are  the  parts 
most  commonly  affected  and  best  studied  from  a  diagnostic  stand- 
point. 

General  atrophy,  as  a  part  of  the  general  wasting  process,  does 
not,  as  a  rule,  affect  even  the  advanced  tuberculous  patient  un- 
til he  has  reached  the  acute  temperature  stage  and  has  suffered 
considerable  loss  of  weight.  Exceptions  to  this  are  now  and  then 
found  in  chronic  progressive  fibrosis,  in  which  a  general  wasting 
may  precede  ulceration.  As  a  rule,  however,  only  regional 
atrophy  of  soft  parts  will  be  found  in  the  tuberculous  up  to  the 
time  that  the  loss  of  several  pounds  of  weight  has  been  sustained. 
Atrophy  confined  to  one  side  is  always  suggestive  of  reflex  degen- 
eration. 

Increased  tone  of  muscles  is  not  so  easily  observed  on  inspec- 
tion in  advanced  tuberculosis  as  it  is  in  early  cases,  but  it  will  be 
observed  at  times.  Regional  atrophy,  on  the  other  hand,  is 
nearly  always  present  and  when  recognized  offers  definite  in- 
formation. It  points  to  some  chronic  or  obsolete  inflammation 
in  the  underlying  lung,  which  in  cases  showing  other  suspicious 
evidence,  is  usually  of  a  tuberculous  nature.  There  seems  to  be 
certain  definite  areas,  in  the  lung  which  reflect  to  definite  areas 
on  the  surface ;  and  when  this  has  been  appreciated  the  diagnostic 
importance  of  atrophy,  together  with  muscle  spasm,  as  signs  of 
disease  within  the  underlying  pulmonary  tissue  will  be  appre- 
ciated. A  sign  of  exceptional  worth  is  a  change  in  contour  of 
the  neck  and  shoulders,  which  occurs  as  a  result  of  the  wasting  of 
the  trapezius.  As  the  trapezius  runs  up  into  the  neck  to  be  in- 
serted into  the  skull  it  normally  forms  a  gentle  curve ;  but,  when 
it  has  undergone  degeneration,  it  wastes  and  forms  an  angle 
more  or  less  sharp,  at  a  lower  level  than  the  normal  curve,  as 
described  on  page  407.  In  slight  lesions  this  is  often  discernible 
and  in  widespread  processes  it  is  very  marked,  as  shown  in 
Figs.  95,  96,  and  97.  The  latter  two  illustrations  are  taken  from 
Brauer,  Schroder  and  Blumenfeld:  Handbuch  der  Tuberkulose, 
vol.  i,  1914.  These  figures  are  shown  by  Brecke  to  illustrate  topo- 
graphical percussion  of  the  apices.  I  have  reproduced  them  to 
show  how  the  degree  of  retraction  of  the  apex  may  be  inferred 
from  inspection.    The  trophic  changes  in  the  muscles  of  the  neck 


468        PHYSICAL  EXAMINATION  IN  PULMONARY  TUBERCULOSIS 

and  upper  chest  suggest  that  the  underlying  lung  tissue  has  been 
the  seat  of  a  chronic  inflammatory  process. 

Atrophy  of  the  skin  shows  as  a  thinning  process,  but  it  is  not 
always  easy  to  detect  on  inspection,  even  if  it  is  widely  distrib- 
uted. Atrophy  of  the  subcutaneous  tissue,  on  the  other  hand,  is 
usually  easy  to  detect  by  the  eye  and  wasting  of  the  muscles  is 
often  quite  plain.  All  of  these  changes  are  confirmed  by  palpa- 
tion. 

Changes  in  Contour  and  Movement  of  Chest  Wall. — Next  to 
the  tissue  changes  above  described,  or  of  equal  importance  on 
inspection,  is  a  careful  observation  and  analysis  of  the  changes 
in  contour  and  movement  of  the  chest  wall.  Change  in  either 
contour  or  movement  means  either  reflex  action  or  compensa- 
tory changes  in  the  tissues  within,  both  of  which  (barring  a  few 
congenital  conditions)  occur  only  as  a  result  of  pathological 
processes;  consequently,  any  departure  from  the  normal  form  of 
the  chest,  or  any  variation  in  the  normal  symmetry  of  the  respira- 
tory movements  should  be  looked  upon  as  being  expressions  of 
past  or  present  disease  within  the  chest,  and  carefully  studied 
for  their  diagnostic  bearing. 

Deficient  movement  of  the  chest  wall  may  be  noted  at  an  apex 
and  suggests  reflex  spasm  of  the  apical  respiratory  muscles  and 
reduced  expansion  on  account  of  the  pathological  changes  in  the 
underlying  pulmonary  tissue.  The  limited  motion  may  also 
affect  the  base,  being  due  to  a  localized  inflammation  of  the 
pleura;  or  the  entire  lung,  being  due  to  the  reflex  stimulation  of 
the  diaphragm  through  the  phrenics  and  the  other  respiratory 
muscles  through  their  respective  nerves;  or  to  a  generally  re- 
duced elasticity  as  a  result  of  extensive  disease  in  the  lung.  This 
limited  motion  of  the  entire  side  may  be  seen  either  when  the 
disease  is  limited  to  a  small  pulmonary  area  at  the  apex,  or  due 
to  a  general  infection.  There  is  also  more  or  less  general  limi- 
tation of  the  motion  of  the  entire  side,  even  though  the  cause  is 
a  localized  pleuritis. 

It  is  impossible  to  discuss  changes  in  contour  apart  from 
changes  in  movement ;  because  if  there  is  a  flattening  or  bulging 
of  the  ribs  it  means  that  there  must  be  a  departure  from  the 
normal  in  the  movements  of  the  parts. 


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CHANGES  IN    CONTOUR  AND   MOVEMENT  469 

If  a  flattened  appearance  is  noted  over  one  or  the  other  apices, 
it  should  be  carefully  examined  to  see  if  it  is  a  real  flattening  of 
the  chest  wall  or  only  a  wasting  of  the  soft  tissues,  which  often 
gives  the  same  appearance;  or  both.  Either  condition  is  sug- 
gestive of  chronic  inflammation  in  the  pulmonary  tissue  under- 
lying. Should  the  flattening  be  at  the  base,  pleurisy  with  ad- 
hesions is  suggested.  Wherever  the  flattening  is,  it  is  usually 
accompanied  by  a  limited  motion  of  the  part  of  the  chest  wall 
overlying  it. 

Enlargement  and  bulging  of  portions  of  the  chest  wall  are  also 
very  commonly  found.  They  are  usually  due  to  compensatory 
emphysema  and  indicate  that  a  destructive  process  has  taken 
place  in  other  portions  of  the  same  lung  or  in  the  other  lung, 
which  has  caused  the  underlying  pulmonary  tissue  to  enlarge. 
The  respiratory  movements  on  the  side  of  the  emphysema  are 
usually  greater  than  normal,  while  those  on  the  other  side,  are 
less  than  normal. 

Bulging  may  also  be  due  to  fluid  or  air  in  the  pleura. 

A  correct  differential  diagnosis  can  often  be  made  by  careful 
analysis  of  the  data  on  inspection. 

A  limitation  of  motion  on  one  side  nearly  always  means  acute 
or  chronic  disease  within  the  lung  or  pleura  on  that  side,  while 
increased  motion  means,  as  a  rule,  compensatory  enlargement  be- 
cause of  an  extensive  destructive  process  on  the  other  side. 

The  following  cases  illustrate  the  relation  of  careful  inspection 
to  diagnosis  in  advanced  tuberculosis : 

Case  I. 

Mr.  0.  Extensive  fibroid  tuberculosis  in  right  lung,  with  cavity  at  apex; 
compensatory  emphysema  at  right  base;  thickened  pleura  at  right  base; 
chronic  fibrosis  upper  portion  left  lung;  compensatory  emphysema  through- 
out left  lung;  heart  displaced  slightly  to  the  right;  right  diaphragm  dis- 
placed upward;  left  diaphragm  displaced  downward. 

Inspection  of  Muscles  and  Subcutaneous  Tissue. — The  chest  is  long  and 
flattened  superiorly.  The  neck  muscles  and  subcutaneous  tissue  over  them, 
as  well  as  those  below  the  clavicle  on  both  sides,  appear  degenerated, 
this  being  more  marked  on  the  right  than  on  the  left.  Both  sterno- 
cleidomastoidei  stand  out  more  prominently  than  normal  because  of  the  degen- 
eration of  the  subcutaneous  tissue  surrounding  them. 

From  the  general  atrophy  of  the  muscles  and  subcutaneous  tissue  over 
the   entire  portion  of  the   right  lung,  I  would  infer   that   there  is   either 


470        PHYSICAL  EXAMINATION  IN   PULMONARY  TUBERCULOSIS 

a  thickened  pleura  or  some  inflammatory  condition  throughout  the  un- 
derlying lung,  or  both.  The  atrophy  of  the  muscles  and  subcutaneous 
tissue  on  the  left  is  confined  to  that  portion  of  the  chest  above  the 
second  rib,  indicating  a  less  extensive  lesion. 

Inspecting  the  chest  posteriorly  we  first  notice  that  it  is  long,  also 
fairly  broad.  We  next  notice  that  the  muscles  over  the  right  shoulder, 
with  the  subcutaneous  tissue  over  them,  are  markedly  degenerated,  the 
right  shoulder  being  considerably  lower  than  the  left.  The  occipital  por- 
tion of  the  trapezius  is  more  degenerated  than  that  on  the  left  side. 
The  degeneration  of  the  muscles  and  subcutaneous  tissue  runs  almost 
to  the  base  on  the  right.  There  is  also  a  degeneration  of  the  muscles 
and  subcutaneous  tissue  at  the  upper  left,  though  of  lesser  degree  and 
lesser  extent  than  that  on  the  right. 

Motility. — Different  portions  of  the  chest  anteriorly  show  unequal  mo- 
tion. We  can  divide  the  chest  into  two  portions,  with  a  line  running 
from  the  left  acromial  process  to  the  sixth  rib  in  the  anterior  axillary 
line  on  the  right  side.  Above  this  line  we  have  decreased  motion  and  be- 
low increased  motion.  The  increased  motion  is  greatest  on  the  left.  From 
this  we  can  infer  from  inspection  that  there  has  been  a  destructive  process 
above  this  line,  more  severe  on  the  right  and  less  extensive  in  the  upper 
left.  We  can  further  infer  that  compensation  has  occurred  and  that  the 
lower  part  of  the  left  lung  is  the  seat  of  a  marked  and  widespread  em- 
physema, and  the  lower  part  of  the  right  is  the  seat  of  a  less  extensive 
emphysema. 

Posteriorly,  the  chest  is  not  so  distinctly  divided  as  to  motion,  although 
a  line  drawn  from  the  outer  third  of  the  shoulder  on  the  left  to  the  lower 
angle  of  the  scapula  on  the  right  will  divide  the  posterior  portion  of  the 
chest  into  two  areas  of  greater  and  lesser  motion.  The  motion,  being  so 
much  less  at  the  upper  right  than  at  the  upper  left,  we  would  infer  that 
there  has  been  a  much  greater  destructive  process  in  the  upper  portion 
of  the  right  lung  than  in  any  other  portion  of  the  chest.  Altered  motion 
in  the  upper  part  of  the  left  as  compared  with  the  lower  portion  of  the 
left,  would  also  indicate  that  there  has  been  some  destructive  process 
in  the  upper  portion  of  the  left  lung.  Greatly  increased  motion  through- 
out the  left,  and  particularly  at  the  base,  would  indicate  the  presence 
of  emphysema.  The  increased  motion  at  the  right  base  as  compared  with 
the  upper  portion  of  the  same  lung,  would  also  indicate  that  there  is 
some  emphysema  at  this  point. 


Case  n. 

Mr.  P.  Chronic  fibro-uleerative  tuberculosis  of  left  lung,  with  large 
secreting  cavities  in  upper  and  lower  lobe;  lung  very  much  contracted; 
entire  mediastinum  drawn  to  left;  scattered  healed  tubercles  through- 
out right  lung;  marked  compensatory  emphysema;  trachea  to  left  of  .me- 
dian line;  heart,  left  border  anterior  axillary  line,  right  border  to  left 
of  median  line;  left  diaphragm  markedly  displaced  upward;  right  dia- 
phragm markedly  displaced  downward.  At  present  time  condition  quies- 
cent. 


CASE  ILLUSTRATING  VALUE  OF  INSPECTION         471 

Inspection  of  Muscles  and  Subcutaneous  Tissue. — Anteriorly  there  is  a 
flattening  over  both  upper  lobes.  The  left  side  somewhat  more  depressed 
than  the  right.  The  motion  throughout  the  left  side  is  diminished — 
markedly  so  at  the  base.  The  left  sternocleidomastoideus  is  markedly 
degenerated,  but  stands  out  more  prominently  than  normal  because  of  the 
degeneration  of  the  subcutaneous  tissue  over  it  and  the  retraction  of 
tissues  under  it.  The  right  sternocleidomastoideus  with  the  subcutaneous 
tissue  over  it  is  degenerated.  The  supraclavicular  notch  is  deepened  on 
both  sides.  The  left  pectoralis  and  the  subcutaneous  tissue  over  it  is 
markedly  degenerated  to  the  fourth  rib.  The  trachea  can  be  seen  dis- 
placed to  the  left.  The  heart  pulsation  is  increased  in  an  area  extend- 
ing from  one  and  one-half  inches  to  the  left  of  the  left  nipple  to  an  inch 
to  the  right  of  the  nipple. 

Posteriorly,  the  left  shoulder  is  much  lower  than  the  right  and  the 
left  side  of  the  chest  is  smaller  than  the  right  throughout.  The  right 
is  somewhat  bulging.  The  angle  formed  by  the  junction  of  the  middle 
with  the  occipital  portion  of  the  trapezius  is  one  inch  lower  on  the  left 
than  on  the  right,  while  the  trapezius,  levator  anguli  scapulas,  rhomboidei, 
and  the  subcutaneous  tissue  over  them,  extending  to  the  base,  is  markedly 
degenerated.  On  the  right  the  trapezius  and  levator  anguli  scapulas  are 
also  slightly  degenerated. 

Motility. — The  motion  on  the  left  is  diminished  throughout  and  on  the 
right  side  is  greater  than  normal. 

From  inspection  alone  we  cannot  tell  whether  or  not  activity  is  pres- 
ent; but,  from  the  fact  that  the  left  side  of  the  chest  is  markedly  smaller 
than  the  right,  together  with  the  lessened  motion  and  the  atrophy  of  the 
muscles  and  subcutaneous  tissue  over  this  side;  and  the  fact  that  the 
trachea  runs  toward  the  left  above  the  jugulum;  and  that  the  maximum 
impulse  of  the  heart  extends  to  the  left  axilla,  we  infer  that  there  has 
been  an  extensive  chronic  destructive  process  involving  the  left  lung. 

From  the  fact  that  the  muscles  over  the  apex  and  the  subcutaneous  tis- 
sue covering  them  on  the  right  side  are  degenerated,  we  would  infer  that  there 
has  also  been  a  chronic  inflammation  affecting  the  underlying  lung  on 
this  side.  From  the  bulging  of  the  right  side  and  the  increased  motion 
throughout  we  would  infer  that  there  is  a  compensatory  emphysema  in- 
volving the  entire  right  lung. 

The  position  and  motion  of  the  acromion  processes  (Korani)  ; 
drooping  of  the  shoulders;  shape  [scaphoid  scapulae  (Graves)], 
position,  and  motion  of  the  scapulae,  are  all  of  diagnostic  import. 
One  should  train  his  powers  of  observation.  It  is  only  necessary 
to  look  at  chests  carefully  and  analytically  in  order  to  form  a 
fairly  correct  idea  of  the  lung  and  pleural  pathology  within. 

We  do  not  expect  to  find  the  classical  phthisical  habitus  except 
in  a  small  proportion  of  cases.  We  expect  to  find  chests  of  the 
same  size  and  shape  as  we  find  regularly  among  well  people,  ex- 
cept as  they  are  deformed  as  a  result  of  the  tuberculosis. 


472        PHYSICAL  EXAMINATION  IN   PULMONARY   TUBERCULOSIS 

PALPATION. 

When  the  data  which  may  be  derived  from  palpation  is  added 
to  that  which  may  be  derived  from  carefully  inspecting  a  chest, 
sufficient  information  is  at  hand,  in  the  majority  of  cases,  pro- 
viding it  is  carefully  analyzed,  to  determine: 

1.  Whether  or  not  there  is  a  pathological  process  in  the  lungs. 

2.  Its  extent. 

3.  Whether  it  is  active,  chronic,  or  healed. 

4.  Whether  sufficient  destruction  has  occurred  to  produce: 

(a)  Compensatory  emphysema. 

(b)  Compensatory  shifting  of  the  mediastinum. 

(c)  Compensatory  shifting  of  the  diaphragm. 

5.  Whether  or  not  pleurisy  is  or  has  been  present  and  if  so 
whether  it  has  resulted  in  marked  adhesions. 

6.  The  nature  of  the  process,  the  density  of  the  infiltration, 
and  whether  or  not  destruction  of  tissue  with  cavity  formation 
has  occurred. 

Inspection  and  palpation  have  not  received  the  attention  that 
they  deserve.  They  require  no  greater  skill  on  the  part  of  the 
examiner  than  percussion  and  auscultation,  but  they  require  to 
be  practiced;  and,  the  data  obtained  requires  thoughtful  analysis 
if  they  are  to  be  of  great  value  to  clinical  medicine. 

Palpation  as  usually  practiced  is  of  limited  usefulness.  It  is 
confined  to  determining  the  vocal  fremitus,  to  demonstrating 
pleural  friction  or  the  fremitus  produced  by  rales,  noting  en- 
larged glands,  locating  the  apex  beat,  determining  expansion  and 
eliciting  pain.  Determining  these  is  the  least  important  func- 
tion of  palpation.  Valuable  information  is  obtained  by  know- 
ing the  location  of  the  heart  beat  and  the  altered  conducting 
power  of  various  pulmonary  areas,  together  with  the  expansile 
activity  of  various  portions  of  the  chest.  The  greatest  value, 
however,  comes  through: 

1.  Studying  the  conditions  of  the  skin,  subcutaneous  tissue 
and  muscles  with  reference  to  the  reflex  motor  and  trophic 
changes  which  they  undergo  in  the  presence  of  acute  and  chronic 
diseases  within  the  thorax. 

2.  Carefully  noting  the  departures  from  the  normal  in  the 


PALPATION  OF  SOFT  STRUCTURES  473 

movements  of  the  various  parts  of  the  thorax  in  confirmation 
of  the  alterations  noted  on  inspection. 

3.  Noting  the  differences  in  density  (resistance)  over  the 
various  portions  of  the  lung  suggestive  of  infiltration,  cavity, 
fibrosis,  emphysema,  thickened  pleura  and  pleural  effusions ;  and 
noting  the  shifting  of  the  mediastinum  and  borders  of  the  lungs. 

Palpation  of  Muscles  and  Subcutaneous  Tissue. — The  impor- 
tance of  palpating  the  soft  parts  covering  the  bony  thorax  for 
degenerations  confined  to  limited  areas  in  advanced  tuberculosis, 
cannot  be  emphasized  too  strongly,  for  each  organ  within  the 
body  is  so  connected  through  its  sympathetic  nerves  with  the 
spinal  nerves  that  any  inflammation  in  that  organ  reflects  some- 
where on  the  surface  in  sensory,  motor  and  trophic  disturbances. 
The  point  where  these  reflex  manifestations  shall  show  them- 
selves is  determined  by  the  nerve  filaments  which  take  their  origin 
from  the  segments  of  the  cord  which  receive  the  impulses  from  the 
nerves  coming  from  the  organ  in  question.  In  the  case  of  the 
lung,  the  cervical  segments  particularly  the  third  and  fourth, 
receive  the  impulses  and  these  give  out  sensory  and  trophic  im- 
pulses to  the  skin  and  subcutaneous  tissue  of  portions  of  the  neck, 
arms  and  chest,  and  motor  and  trophic  impulses  particularly  to 
the  muscles  of  respiration,  including  the  diaphragm. 

As  previously  mentioned,  this  circumscribed  (regional)  atrophy 
is  not  the  same  as  the  general  wasting.  It  occurs  whenever  and 
wherever  an  inflammation  has  existed  long  enough  to  become 
chronic,  whether  it  was  sufficiently  extensive  to  interfere  with 
the  general  health  of  the  individual  or  not.  "We  detect  localized 
areas  of  atrophy  of  the  skin  and  subcutaneous  tissue  over  the 
supraclavicular  notch,  or  over  the  first  interspace,  or  above  the 
spine  of  the  scapula,  also  the  wasting  of  the  sternocleido- 
mastoideus,  upper  fibers  of  the  pectoralis  and  trapezius  when  the 
underlying  apex  is  the  seat  of  a  small,  chronic  or  healed  tuber- 
culous lesion.  We  see  this  extend  and  become  widespread,  in- 
volving the  tissue  to  the  third  and  fourth  rib  and  down  to  the 
base  of  the  scapula,  or  lower,  as  the  tuberculous  process  extends 
lower  and  lower.  If  the  pathological  process  in  the  lung  re- 
mains confined  to  one  lung,  the  atrophy  of  the  skin,  subcutaneous 
tissues,  and  muscles  will  be  confined  to  the  same  side,  until  such 


474        PHYSICAL  EXAMINATION  IN  PULMONARY  TUBERCULOSIS 

time  as  the  general  wasting  is  sufficient  to  manifest  itself,  then 
all  the  tissues  of  the  body  partake  of  it,  and  the  regional  wasting 
is  overshadowed  by  the  general  process  and  is  hard  to  determine. 
Prior  to  this  time,  however,  any  atrophy  of  the  soft  parts  should 
be  carefully  scrutinized  to  see  if  it  is  limited  in  its  extent,  and 
regional  in  character. 

The  regional  wasting  can  be  determined  by  inspection,  but  it 
is  confirmed,  and  at  times,  better  determined  by  palpation. 

When  the  palpating  fingers  press  upon  the  soft  tissues  which 
are  atrophied,  several  different  conditions  may  be  noted.  The 
skin  may  feel  thin  and  loose.  If  taken  between  the  fingers  it  may 
be  noted  that  the  skin  over  the  first  interspace  is  thinner  than 
that  over  the  first  on  the  other  side  or  that  over  the  second  in- 
terspace of  the  same  side. 

The  subcutaneous  tissue  may  appear  to  be  wasted.  The  usual 
cushion  is  not  there.  The  fibers  of  the  underlying  muscles  or 
the  underlying  bones  are  felt  more  distinctly  than  in  areas  close 
at  hand  or  those  on  the  other  side.  The  skin  is  not  bound  firmly 
to  the  underlying  tissues  but  can  be  picked  up  and  lifted  from 
them  with  ease. 

The  muscles  feel  wasted.  The  bundles  are  looser  and  more  free- 
ly movable  in  the  tissues  surrounding  them  than  they  should  be — 
looser  than  those  adjacent.  The  bundles  are  made  out  more 
easily  and  they  separate  more  readily  than  they  do  in  normal 
muscles.  The  substance  of  the  muscle,  as  a  whole,  is  reduced 
in  amount.  This  shows  exceptionally  well  in  the  sternocleido- 
mastoideus  where  it  can  be  taken  between  the  thumb  and  finger 
and  its  size  and  texture  compared  with  its  mate.  The  degree  of 
wasting  present  can  also  be  detected  by  pressing  the  soft  tissues 
gently  against  the  chest  wall  and  noting  the  comparative  lack  of 
tissue  where  the  regional  wasting  has  taken  place. 

A  normal  muscle  is  more  or  less  compact,  often  rotund,  and 
feels  like  one  firm  elastic  mass,  while  a  wasted  muscle  has  lost 
its  tone  as  well  as  compactness  and  rotundity. 

Finally  the  feeling  of  the  tissues  which  are  atrophied  is  dis- 
tinctive. The  normal  elasticity  is  gone  and  the  tissues  give  a 
doughy  sensation  to  the  finger. 

"While  spasm  of  the  muscles  may  often  be  detected  in  advanced 


MOTILITY   OF   CHEST   WALL  475 

eases  when  the  disease  in  the  lung  is  a  renewed  activity  in  an 
old  focus,  yet  this  is  attended  by  difficulties  owing  to  the  in- 
creased tone  (spasm)  being  difficult  to  recognize  on  account  of 
the  atrophied  muscle.  Increased  tone  (spasm.)  is  important,  how- 
ever, in  determining  whether  the  disease  has  extended  to  the 
other  side  and  in  determining  whether  it  has  extended  to  other 
areas  in  the  lung. 

Degeneration  of  the  muscles  covering  the  apex,  and  the  skin 
and  subcutaneous  tissue  over  them,  is  suspicious  of  a  tuberculous 
lesion,  chronic  in  nature,  affecting  the  underlying  apex.  If  the 
lower  fibers  of  the  pectoralis  and  the  overlying  skin  and  subcu- 
taneous tissues  are  also  involved,  this  is  suspicious  of  a  chronic 
tuberculosis  involving  the  entire  upper  lobe.  If  the  rhom- 
boidei  and  the  skin  and  subcutaneous  tissue  over  them  are  de- 
generated, it  indicates  that  the  apex  of  the  lower  lobe  is  the 
seat  of  a  chronic  inflammation,  usually  tuberculosis. 

Muscles  also  degenerate  and  lengthen  as  a  result  of  use.  The 
drop  of  the  right  shoulder  in  part  is  due  to  this.  It  is,  at  times, 
difficult  to  tell  whether  a  right-sided  degeneration  of  the  apical 
muscles  is  due  to  occupational  influences  or  to  reflex  trophic  dis- 
turbances. Conditions  found  in  these  muscles  are  at  times  difficult 
to  interpret.  Two  facts  have  helped  me:  first,  the  sternocleido- 
mastoideus  is  not  subject  to  many  occupational  influences ;  so  a. 
one-sided  spasm  or  degeneration  of  the  apical  group  of  muscles, 
including  this  one,  points  to  a  reflex  trophic  cause  for  the  degen- 
eration: second,  the  skin  and  subcutaneous  tissue  does  not 
atrophy  as  a  result  of  occupational  influences,  but  does  so  as  a 
result  of  reflex  trophic  irritation.  Again,  if  the  atrophy  is  due 
to  pathological  changes  in  the  lung,  this  will  be  detected  on  deep 
palpation,  percussion,  and  auscultation. 

Motility  of  Chest  Wall. — Either  a  limitation  or  exaggeration  of 
movement  of  any  portion  of  the  chest  is  at  times  more  easily  de- 
tected by  palpation  than  by  inspection.  Any  such  departure 
from  the  normal  movements  of  the  chest  is  suspicious  of  patho- 
logical changes  either  in  the  lung  or  pleura,  or  both. 

In  advanced  tuberculosis  lessened  motion  of  the  diaphragm  or 
chest  wall  may  be  due  to  acute  or  chronic  inflammation  of  the 
pleura,  or  to  an  active  infiltration  or  an  old  chronic  fibrosis  in 


476        PHYSICAL  EXAMINATION  IN  PULMONARY  TUBERCULOSIS 

the  lung.  Increased  motion  of  the  diaphragm,  or  chest  wall,  is  a 
compensatory  phenomenon  and  may  be  found  on  the  side  opposite 
to  an  acute  pleurisy  or  on  the  side  of  a  compensatory  emphysema. 

A  limitation  of  motion  of  the  upper  portion  of  the  chest  may 
be  due  to  an  active  inflammation  at  that  apex,  the  lessened  mo- 
tion resulting  from  the  combined  action  of  the  thickening  of  the 
pleura  and  the  reflex  spasm  of  the  respiratory  muscles  fixing  the 
thorax,  and  the  lack  of  elasticity  in  the  tissues,  resulting  from 
the  infiltrating  inflammation  in  the  lung;  or  fibroid  changes  in 
the  pulmonary  tissue. 

Departures  from  the  normal  respiratory  movements  can  best 
be  interpreted  when  considered  in  conjunction  with  the  trophic 
and  motor  changes  in  the  soft  parts. 

Determination  of  Different  Degrees  of  Density  by  Palpation. — 
"The  principle  involved  in  palpation  and  percussion  is  the  same 
when  the  interpretation  of  the  latter  is  based  on  the  sensation 
conveyed  to  the  finger  rather  than  to  the  sound  emitted  by  the 
blow.  Palpation,  no  matter  how  delicately  carried  out,  sets  up 
vibrations  and  disturbs  the  equilibrium  of  the  tissues  on  which 
it  is  practiced.  The  touch  starts  waves  which  penetrate  the  tis- 
sues and,  according  to  the  manner  in  which  these  waves  are  in- 
terfered with,  do  the  sensations  conveyed  to  the  finger  differ. 
So,  whether  we  generate  the  vibrations  by  touch  or  by  a  gentle 
stroke  the  effect  is  the  same,  a  varied  penetration  and  varied  in- 
terference with  the  vibrations  and  a  varied  perception  through 
the  palpating  finger,  which  is  interpreted  as  meaning  different 
degrees  of  density  of  the  underlying  tissues."1 

By  carefully  palpating,  the  examiner  will  learn  that  different 
degrees  of  density  are  transmitted  to  the  finger  through  the 
sense  of  touch,  the  same  as  they  are  through  sound  or  percus- 
sion resistance.  Conditions  which  are  recognized  by  differences 
in  pitch  and  quality  of  the  note  elicited  on  stroke,  and  by  dif- 
ferent degrees  of  resistance  to  the  finger  used  as  a  pleximeter  on 
percussion,  also  convey  different  impressions  through  the  sense 
of  touch  by  which  we  are  able  to  recognize  normal  and  abnormal 
conditions  within  the  body.     Light  touch  palpation  affords  the 


jPottenger:     Muscle  Spasm  and  Degeneration  and  Light  Touch  Palpation,  C.  V.  Mosby 
Co.,   St.  Louis,  1912. 


PERCUSSION  477 

greatest  acuteness  in  interpretation  because  the  sense  of  feeling 
in  the  finger  pulps  is  utilized  to  greatest  advantage.  Various 
degrees  of  palpation  should  be  utilized,  however,  for  different 
conditions,  as  the  observer  will  soon  learn  for  himself. 

The  normal  lung,  the  borders  of  the  lung  whether  within  nor- 
mal limits  or  shifted,  infiltrations,  fibroid  areas,  cavity,  emphy- 
sema, pleural  effusions,  pneumothorax,  thickened  pleura,  media- 
stinal tumors  and  enlarged  peribronchial  glands ;  in  fact  all  con- 
ditions which  can  be  determined  by  percussion,  can  be  deter- 
mined by  palpation.  The  peculiar  characteristics  of  each  of  these 
as  determined  by  the  palpating  finger  I  shall  discuss  later  in  con- 
junction with  the  other  methods  of  examination. 

PERCUSSION. 

The  principles  and  technic  of  percussion  are  the  same  as  in 
early  tuberculosis  as  discussed  on  page  417,  although  a  greater 
variety  of  changes  will  be  noted  because  of  the  more  varied  and 
more  extensive  character  of  the  pathological  changes  found. 

In  such  a  complex  condition  as  advanced  tuberculosis,  where 
all  grades  of  infiltration,  various  degrees  of  excavation  and  com- 
pensation, such  conditions  as  pleural  effusion,  pneumothorax, 
thickened  pleura,  and  compensatory  emphysema  are  found,  it 
can  readily  be  seen  that  we  must  draw  conclusions  from  percus- 
sion only  after  careful  consideration.  Not  only  the  changes  in 
percussion  note,  but  the  different  degrees  of  resistance  to  the 
finger  must  be  carefully  noted. 

The  condition  of  the  muscles  and  subcutaneous  tissue  must  also 
be  carefully  observed,  and  allowance  must  be  made  for  increased 
tone  as  noted  when  the  muscle  is  overdeveloped  or  thrown  into 
spasm  reflexly,  and  decreased  tone,  when  it  and  the  subcu- 
taneous tissue  is  degenerated  as  a  result  of  occupational  change 
or  reflex  atrophy.  Any  increase  in  muscle  substance  or  any 
increase  in  tone  in  individual  muscles  is  followed  by  an  impair- 
ment of  the  note  and  higher  pitch,  also  by  an  increased  resistance 
to  the  finger.  Any  wasting  on  the  other  hand,  no  matter  from 
what  cause,  is  followed  by  a  corresponding  reduction  in  dull- 
ness and  lowering  of  pitch,  as  well  as  a  reduction  of  resistance 


478        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

to  the  finger.    For  a  more  complete  discussion  of  factors  which 
alter  percussion  findings  see  Chapter  XV. 

AUSCULTATION. 

Auscultation  in  advanced  tuberculosis  shows  many  departures 
from  the  normal  in  the  respiratory  sounds.  These  departures 
consist  of  a  disturbance  in  the  rhythm,  pitch  and  quality  of  the 
respiratory  murmur;  a  number  of  adventitious  sounds;  and  al- 
terations in  the  manner  in  which  the  voice  is  transmitted. 

It  is  impossible  to  describe  in  detail  all  the  changes  which  oc- 
cur in  the  respiratory  murmur  in  advanced  tuberculosis  for  they 
vary  under  different  circumstances.  While  there  are  certain 
characteristic  sounds  which  belong  to  infiltration,  others  to  soften- 
ing and  cavity  formation,  and  still  others  to  fibrosis;  yet  these 
processes  are  found  in  such  varied  combinations  and  differ  so 
in  their  extent;  and  the  sounds  are  so  modified  by  the  state  of 
the  remaining  portions  of  the  lung,  the  condition  of  the  pleura 
and  the  state  of  the  muscles  and  subcutaneous  tissue  through 
which  they  are  heard,  that  we  must  be  prepared  to  find  all  kinds 
of  combinations  of  sounds  in  advanced  tuberculosis. 

Respiratory  Rhythm. — The  normal  relationship  of  inspiration 
to  expiration  is  disturbed  in  such  a  manner  that  as  infiltration 
increases  expiration  gradually  lengthens  until  it  finally  becomes 
equal  to  or  longer  than  inspiration.  The  change  in  rhythm  is 
usually  accounted  for  in  tuberculosis  by  the  consolidation  caus- 
ing the  bronchi  to  be  more  rigid  and  the  tissues  less  elastic,  as  a 
result  of  which  the  air  is  forced  out  of  the  tissue  more  slowly 
and  the  sound  emitted  transmitted  more  readily.  So  it  can  be 
understood  that  all  degrees  of  prolonged  expiration  exist  in  tis- 
sues the  character  of  which  varies  from  slight  infiltration  to 
marked  fibrosis  or  cavities  and  dilated  bronchi  surrounded  by 
dense  fibrous  tissue.  I  do  not  doubt  that  the  atrophy  of  the  soft 
tissues  external  to  the  pleura  also  has  its  influence  by  removing  a 
compressing  influence  on  the  thorax,  thus  prolonging  the  expiratory 
phase.  When  compensatory  emphysema  occurs,  then  the  prolonged 
expiration  is  due  to  an  inability  of  the  pulmonary  tissue  to  contract 
and  expel  the  air,  but  the  quality  of  the  note  differs  wholly  because 


QUALITY   OP   RESPIRATORY   NOTE  479 

it  lacks  the  conditions  for  ready  transmission.  While  the  expira- 
tory note  of  consolidation  and  scar  tissue  is  more  intense  and 
higher  in  pitch  than  normal,  that  of  compensatory  emphysema  is 
lower  pitched  and  weaker  than  normal. 

Quality  of  Note. — The  quality  of  the  respiratory  note  also 
varies  greatly.  As  the  pathological  changes  in  the  lung  extend, 
the  soft  breezy  normal  inspiration  gives  way  to  a  rough,  harsh, 
or  combined  rough  and  harsh,  inspiration  with  pitch  higher  than 
normal.  The  same  is  true  of  expiration.  Expiration,  as  a  rule, 
is  equal  to  or  of  higher  pitch  than  inspiration  when  consolida- 
tion is  present;  and  particularly  in  the  presence  of  dense  fibrous 
tissue.  When  excavation  has  occurred,  however,  there  is  a 
tendency  for  the  pitch  of  the  expiratory  note  to  be  lower  than 
that  of  inspiration,  unless  the  cavity  is  small  and  surrounded  by 
large  amounts  of  dense  fibrous  tissue.  This  is  an  important  sign 
of  cavity. 

The  roughness  wThich  so  often  characterizes  the  respiratory  note 
in  advanced  tuberculosis  probably  has  many  factors  which  enter 
into  its  composition.  It  has  been  suggested  that  roughness  in 
early  tuberculosis  may  be  caused  by  an  unequal  entrance  of  air 
into  the  tissues.  The  condition  which  would  produce  roughness 
because  of  such  unequal  entrance,  is  found  to  an  exaggerated 
degree  in  advanced  tuberculosis,  because  of  the  varied  patho- 
logical processes  which  are  present.  In  advanced  tuberculosis 
there  is  often  found  coexisting  in  the  same  lung,  or  even  the 
same  lobe,  varying  degrees  of  infiltration  accompanied  by  vary- 
ing degrees  of  exudation,  areas  of  necrosis,  excavation  and 
fibrosis. 

The  effect  of  the  muscles  in  producing  the  roughened  char- 
acter of  the  note  must  also  be  considered.  The  peculiar  rough, 
rumbling  respiratory  note  over  compensatory  emphysema  un- 
doubtedly has  a  large  muscular  element  in  its  production.  Thick- 
enings of  the  pleura  which  are  stretched  during  respiration  also 
add  a  roughened  character. 

Changes  in  the  respiratory  note  in  advanced  tuberculosis  con- 
sist in  replacing  the  normal  vesicular  murmur  by  one  which,  at 
first,  is  somewhat  bronchial  in  character,  but  which,  later,  after 


480         PHYSICAL   EXAMINATION   IN   PULMONARY   TUBERCULOSIS 

pathological  changes  become  sufficiently  extensive,  becomes  en- 
tirely so.  This,  in  turn,  becomes  amphoric  when  excavation  oc- 
curs. 

Rales. — Rales  or  adventitious  sounds  accompany  the  respira- 
tory murmur  in  nearly  all  cases  of  widespread  pulmonary  tuber- 
culosis. These  rales  vary  in  nature  as  they  differ  in  the  manner 
of  their  production.  Rales  are  divided  into  moist  and  dry.  Some 
writers  claim  that  all  intrapulmonary  rales  originate  with  mois- 
ture. At  times  stretching  of  scar  tissue,  pleural  adhesions  and 
muscles  will  produce  sounds  that  cannot  be  differentiated  from 
the  intrapulmonary  sounds.  The  methods  of  differentiating  intra- 
pulmonary and  extrapulmonary  rales  is  uncertain. 

Rales  are  affected  by  the  depth  of  respiration,  cough,  position 
of  the  patient,  whether  the  patient  has  coughed  and  expectorated 
immediately  prior  to  examination  or  not,  the  time  of  the  day, 
fever,  conditions  of  weather,  and  many  other  factors,  as  well  as 
the  pathological  process  which  produces  them. 

By  making  frequent  examinations  of  a  tuberculous  lung  over 
a  prolonged  period  of  time  it  will  be  noted  that  the  rales  are 
characterized  by  constancy.  When  rales  appear  in  an  area  they 
go  through  certain  evolutionary  changes  but  do  not  leave  the 
part  wholly  until  healing  or  wholesale  destruction  with  cavity 
formation  has  taken  place  and  not  always  then.  They  might  be 
temporarily  put  in  abeyance  by  a  pleural  exudate  or  pneumo- 
thorax, but  they  do  not  disappear  until  the  cause  disappears. 
Many  rales  remain  permanently,  even  after  an  apparent  healing 
has  occurred. 

Rales,  to  a  certain  extent,  indicate  the  nature  of  the  pathological 
process  underlying.  Probably,  if  we  were  more  expert  in  our 
interpretation,  they  would  be  even  more  accurate.  The  first 
rales  which  make  their  appearance  are  those  which  accompany 
infiltration,  the  so-called  dry  crackle  or  crepitant  rales.  They  are 
found  in  the  areas  which  have  been  recently  affected.  At  this 
time  the  process  is  accompanied  by  very  little  exudation  into  the 
tissues  surrounding  the  tubercles.  The  rales  are  confined  to  the 
finer  air  passages,  largely  to  the  air  cells.  The  result  is  that 
the  rales  are  fine  and  dry  in  character  and  are  elicited  best  by 
increased  inspiratory  effort  or  by  this  preceded  by  a  cough. 


RALES  .  481 

In  auscultating  over  early  active  infiltrations,  these  rales  are 
often  heard  in  small  showers  after  coughing.  In  more  advanced 
lesions  in  which  the  bacilli  are  multiplying,  tubercles  are  soften- 
ing and  toxins  are  diffusing  into  adjacent  tissues,  a  greater  de- 
gree of  inflammation  exists  and  this  is  accompanied  by  increased 
exudation.  This  process  is  accompanied  by  increased  moisture 
in  the  air  passages  which  finds  its  way  into  the  bronchi  of  differ- 
ent sizes  and  in  this  way  produces  moist  rales,  both  medium  and 
large  in  character. 

In  localized  areas  of  necrosis  with  cavity  formation  medium  or 
large  rales  may  persist  for  a  long  time.  The  location  of  con- 
glomerate caseating  tubercle  is  often  marked  by  the  persistence 
of  medium  and  large  rales  heard  over  a  given  area  for  a  con- 
siderable time.  If  extensive  excavation  takes  place  the  rales  may 
disappear  wholly,  or  decrease  in  number  coincident  with  the 
sloughing  of  the  tissue.  Where  one  has  been  examining  patients 
repeatedly,  this  cavity  formation  may  be  suspected  by  the  ab- 
sence of  medium  and  large  rales  which  have  persisted  for  a  long 
time.  On  the  other  hand,  there  are  times  when,  coincident  with 
such  pathological  changes,  the  rales  become  coarser  and  bub- 
bling or  gurgling  in  character,  owing  to  the  air  forcing  its  way 
through  the  mucus  or  pus  which  is  present  in  the  cavity. 

When  healing  is  taking  place,  the  multiplication  of  bacilli  in 
the  tubercles  is  lessening,  and  the  amount  of  toxins  diffusing  into 
the  adjacent  tissue  is  decreasing,  consequently  the  exudative  in- 
flammation which  accompanies  active  inflammation  decreases  and 
the  amount  of  moisture  which  shows  as  moist  rales,  lessens  and 
the  tissues  appear  to  the  examiner  to  be  of  a  dryer  character. 

This  statement  must  not  be  considered  as  conflicting  with  the 
fact,  which  is  often  evident  in  the  fibro-ulcerative  type  of  tuber- 
culosis, that  the  amount  of  sputum  does  not  necessarily  lessen  in 
the  proportion  to  the  lessening  of  rales.  The  explanation  is  that 
the  sputum  is  coming  from  ulcerative  surfaces  within  cavities 
instead  of  from  the  bronchial  mucous  membrane. 

Not  only  do  we  have  the  three  types  of  distinctly  moist  rales 
just  described,  but  there  are  squeaks,  wheezes,  and  ronchi  of 
great  variety.  Often  a  persistent  squeak  at  some  point  in  the 
pulmonary  tissue  indicates  that  softening  and  ulceration  is  tak- 


482        PHYSICAL  EXAMINATION   IN  PULMONARY  TUBERCULOSIS 

ing  place.  Wheezes  and  ronchi  are  at  times  present  in  such  num- 
bers that  the  picture  resembles  asthma. 

Adventitious  Sounds  Resembling"  Intrapulmonary  Rales. — The 
examiner  is  often  much  confused  in  knowing  how  to  interpret 
the  adventitious  sounds  which  are  heard  upon  auscultation.  I 
have  just  described  many  different  types  of  rales  that  have  their 
origin  within  the  lung.  These  rales  would  seem  to  be  more  or 
less  distinctive  of  certain  conditions  which  produce  them.  There 
are,  however,  many  sounds  heard  on  auscultation,  which  cannot 
be  readily  differentiated  from  the  intrapulmonary  rales  just 
mentioned.  Pleural  crepitations  are,  at  times,  very  difficult  to 
differentiate  from  intrapulmonary  rales.  The  muscles  also,  now 
and  then,  give  us  sounds  which  cause  difficulty  in  diagnosis. 
Sometimes  these  are  fine  crepitations,  sometimes  they  simulate 
medium,  and,  at  other  times  even  coarse  rales;  or,  they  may  even 
take  the  form  of  creaks  and  squeaks.  We  find  many  of  these  near 
the  apex  where  the  pleura  becomes  thickened,  and  the  adjacent 
musculature  and  tissue  also  partake  in  the  inflammatory  process, 
as  has  been  described  by  Coplin  (see  Volume  II,  Chapter  XXV). 
These  rales  may  be  found  in  any  part  of  the  lung  where  a  thick- 
ened pleura  and  chronically  inflamed  muscles  exist. 

Swallowing  will  often  produce  sounds  which  simulate  rales, 
when  one  is  listening  over  the  apices.  After  the  patient  has  been 
observed  for  a  long  time,  the  true  nature  of  these  rales  can  usually 
be  made  out  by  the  fact  of  their  persistence  and  the  knowledge 
of  the  changes  which  have  occurred  in  the  underlying  pulmonary 
tissue. 

Where  widespread  pleural  adhesions  are  present  we  may  often 
infer  that  the  rales  are  not  intrapulmonary  because  of  the  fact 
that  the  amount  of  moisture  which  would  be  represented  by  such 
widely  distributed  pulmonary  rales,  is  not  in  keeping  with  the 
amount  of  sputum  present. 

Extensive  Infiltration  in  One  Lung. — In  discussing  the  more 
common  conditions  which  are  met  in  the  lung  in  advanced  pul- 
monary tuberculosis  I  shall  first  consider  extensive  infiltration. 

Inspection. — What  can  be  determined  by  inspection  will  de- 
pend, as  previously  mentioned,  on  whether  the  infiltration  in  the 
lung  is  recent  or  of  long-standing,  and  upon  whether  it  is  a  new 


EXTENSIVE  INFILTRATION  483 

infiltration  in  tissue  which  has  not  previously  been  infected,  or 
a  renewed  activity  in  an  old  lesion. 

No  matter  whether  the  infiltration  is  a  new  or  old  one,  if  it 
is  active,  it  causes  a  limitation  of  the  respiratory  movement  of 
the  chest  wall.  All  active  inflammations  of  the  pulmonary  par- 
enchyma cause  reflex  motor  disturbance  in  the  muscles  of  respira- 
tion which  results  in  limited  motion.  The  diaphragm,  being  the 
chief  muscle  of  respiration,  and  being  affected  by  this  reflex,  acts 
in  such  a  manner  as  to  greatly  alter  the  respiratory  movements. 
Interference  with  the  elasticity  of  the  pulmonary  tissue,  likewise 
causes  diminished  motion.  Sometimes  this  limited  motion  is  most 
pronounced  at  the  apex.  The  apex  is  the  usual  site  of  the  first 
acutely  active  tuberculous  process  in  the  lung,  and  when  the 
disease  is  extensive,  it  is  nearly  always  accompanied  by  pleural 
adhesions  which  also  limit  the  respiratory  motion.  At  other 
times,  limited  motion  is  most  marked  at  the  base;  or,  again,  it 
may  be  equally  distributed  over  the  entire  side. 

Limited  motion  is  best  detected,  as  a  rule,  during  normal  easy 
respiration.  At  times,  however,  it  is  best  elicited  on  deep  inspira- 
tion. Examination  should  be  made  during  both  shallow  and 
forced  respiration. 

The  ehanges  in  the  soft  parts  are  often  plainly  visible,  as  de- 
scribed in  discussing  early  tuberculosis  in  Chapter  XV.  In  early 
tuberculosis,  increased  tone  (spasm)  of  the  muscles  is  of  the 
greatest  diagnostic  significance.  In  advanced  tuberculosis,  as  a 
rule,  degeneration  is  most  evident  and  of  greater  diagnostic  im- 
portance than  increased  tone.  This  will  vary,  however,  accord- 
ing to  the  activity  of  the  pathological  process;  whether  it  in- 
volves tissues  which  have  not  been  previously  infected;  or  is  an 
increased  activity  in  an  old  focus.  This  latter  is  the  condition 
usually  met  in  advanced  tuberculosis. 

Whenever  a  pathological  process  has  existed  over  a  pro- 
longed period  of  time  and  become  chronic  in  character,  the  soft 
tissues  over  those  portions  of  that  lung,  which  are  segmentally  in 
reflex  communication  with  the  inflammatory  areas  in  the  lung, 
through  the  sympathetics,  will  show  degeneration;  consequently, 
degeneration  of  the  soft  tissues  covering  the  chest,  when  regional 


484        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

in  character,  becomes  a  very  important  sign  of  chronic  inflam- 
mation in  the  underlying  pulmonary  tissue. 

If  the  inflammation  is  recent,  aside  from  the  degeneration,  the 
muscles  will  show  increased  tone.  This,  at  times  can  readily  be 
detected  on  inspection,  particularly  in  the  sternocleidomastoid- 
eus,  trapezius  and  levator  anguli  scapulae. 

If  the  process  has  been  chronic  and  the  muscles  have  accord- 
ingly degenerated,  then  it  may  be  difficult  or  impossible  to  de- 
termine the  increased  tone  on  inspection;  in  fact,  such  an  in- 
creased tone  may  be,  now  and  then,  especially  in  individuals  with 
weak  musculature,  difficult  to  determine  with  certainty  on  pal- 
pation. 

Palpation. — Palpation  shows  increased  tone  of  the  muscles  cov- 
ering the  apex  and  upper  portion  of  the  lung  if  the  disease  is  ac- 
tive and  of  recent  extension.  Degeneration  of  these  same  mus- 
cles and  the  subcutaneous  tissues  overlying  them  shows  if  the 
disease  is  of  long  duration.  This  is  shown  by  the  tissues  pre- 
senting a  soft,  doughy,  inelastic  sensation  to  the  palpating  fin- 
gers, and  by  the  fact  that  the  cushion  of  subcutaneous  tissue, 
likewise  the  mass  of  muscles  is  smaller  in  amount  than  normal. 
Increased  tone  may  be  noted  in  the  degenerated  muscles  if  the 
disease  is  chronic,  but  still  active.  At  times,  however,  the  de- 
generation will  be  so  marked  that  the  increased  tone  may  not  be 
detected.  Even  those  with  most  practice  may  have  difficulty  in 
being  sure  of  the  increased  tone  under  these  circumstances.  I 
would  call  attention  to  the  fact,  however,  that  the  sternoeleido- 
mastoideus,  trapezius,  and  levator  anguli  scapulae  should  be  ex- 
amined most  carefully  under  such  conditions,  for  they  will  usu- 
ally reveal  the  true  condition  of  the  muscles  in  general. 

Palpation  corroborates  the  lessened  excursion  of  the  side  in- 
volved. As  a  rule,  this  important  sign  can  be  determined  better 
by  palpation  than  by  inspection.  The  hands  should  be  laid  on 
lightly,  however,  for  even  slight  pressure  will  restrict  the  move- 
ments. 

Through  palpation  we  also  determine  the  relative  density  of 
the  lung  tissue.  If  one  is  endeavoring  to  determine  the  areas 
of  infiltration,  it  is  better  to  palpate  from  areas  of  lesser  density 
to  those  of  greater  density;  consequently,  in  palpating  lungs 


EXTENSIVE  INFILTRATION  485 

it  is  preferable  to  begin  at  the  base  and  go  upward,  unless 
thickened  pleura  interferes.  When  the  borders  of  the  areas  of 
infiltration  are  reached,  an  increased  sense  of  resistance  will  be 
noted  by  the  palpating  finger.  One  must  be  on  his  guard  in 
palpating  the  total  resistance  of  the  lung  because  there  are  other 
factors  than  the  thickened  pulmonary  tissue  which  enter  in  and 
have  a  tendency  to  vitiate  the  findings,  the  same  as  they  do  in 
percussion.  For  example,  in  palpating  in  the  axillary  line,  when 
one  comes  to  the  folds  of  the  pectoral  muscles  an  increased  re- 
sistance is  noted.  This  must  not  be  considered  as  being  neces- 
sarily due  to  the  pathological  changes  in  the  lung.  It  must  be 
considered  in  connection  with  the  fact  that  the  more  tissue 
through  which  one  palpates,  the  greater  the  resistance  to  the 
fingers.  Another  area  which  offers  difficulties  is  the  interscapu- 
lar region.  An  increased  feeling  of  resistance  is  recognized  by 
the  palpating  fingers  when  the  lower  border  of  the  rhomboidei 
muscles  is  reached.  This  may  be  mistaken  for  infiltration.  These 
same  muscles  give  difficulty,  and  often  mislead,  in  percussion 
the  same  as  in  palpation.  Infiltrations  in  the  lung  are  detected 
as  readily  by  palpation  as  by  percussion. 

If  the  existing  infiltration  is  sufficiently  extensive  to  call  for 
compensatory  changes  in  other  portions  of  the  lung,  or  in  the 
opposite  lung,  a  lessened  total  density  may  be  noted  over  the 
emphysematous  portions.  This  lessened  total  density  is  readily 
determined  by  comparing  it  with  the  increased  deep  resistance 
over  the  area  of  infiltration.  Palpating  over  marked  emphysema, 
however,  often  gives  an  increased  resistance  to  the  palpating 
finger,  which  may  be  mistaken  for  increased  density  in  the  un- 
derlying pulmonary  tissue.  This  is  due  to  the  fact  that  marked 
emphysema  causes  an  increased  tension  of  the  intercostal  mus- 
cles which  shows  as  increased  resistance  to  the  palpating  finger. 
If,  under  such  circumstances,  however,  one  will  palpate  more 
deeply  he  will  readily  see  that  he  is  palpating  over  increased 
tension,  but  not  over  increased  density. 

Permission.— Percussion  will  give  results  according  to  the 
state  of  the  tissues  percussed.  The  examiner  must  bear  in  mind, 
as  mentioned  in  connection  with  percussion  in  early  tuberculosis 
(page  420),  that  the  percussion  note  and  the  degree  of  resist- 


486        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

ance  conveyed  to  the  finger  are  influenced  not  only  by  the  state 
of  the  underlying  pulmonary  tissue,  but  by  the  pleura,  bony 
thorax,  subcutaneous  tissue  and  muscles.  If  the  muscles  are 
hypertrophied  from  use  or  increased  in  tone  (spasm)  because 
of  the  reflex  irritation  from  the  pulmonary  inflammation,  the 
percussion  note  will  be  higher  and  the  resistance  greater  than 
normal.  If  they  and  the  subcutaneous  tissue  are  atrophied 
from  reflex  trophic  changes  or  from  disuse  following  hyper- 
trophy, then  the  note  will  be  more  resonant  and  the  resistance 
less  than  normal.  Thickened  pleura  will  also  cause  higher  pitch 
of  the  note  and  greater  resistance  to  the  finger. 

An  infiltrated  lung  may  show  varying  degrees  of  infiltration, 
each  of  which  will  give  a  different  character  to  the  percussion 
note,  even  though  the  coverings  of  the  lung  are  always  the  same. 

These  facts  show  that  there  can  be  no  definite  note  or  de- 
gree of  resistance  which  will  always  mean  a  given  degree  of  in- 
filtration in  a  lung.  They  show  too  that  the  percussion  cannot 
be  accurately  interpreted  without  estimating  the  effect  of  the 
changes  in  the  coverings  of  the  lung,  particularly  the  amount 
and  the  degree  of  increased  tone  or  wasting  of  the  muscles ;  the 
amount  and  the  degree  of  wasting  of  the  subcutaneous  tissue, 
and  the  amount  of  thickening  of  the  pleura,  when  present.  Failure 
to  appreciate  this  is  the  cause  of  much  error. 

Oftentimes  an  infiltration  of  greater  density  than  really  ex- 
ists will  be  indicated  by  the  higher  pitched  note  or  greater  re- 
sistance to  the  finger  on  percussion  which  results  from  the  re- 
flex increased  tone  (spasm)  of  the  muscles  overlying  the  lung. 
While  this  condition  is  most  often  met  in  early  tuberculosis,  yet 
it  is  not  infrequent  in  advanced  cases  when  the  disease  has 
spread  quickly.  This  is  particularly  apt  to  occur  over  the 
trapezius,  levator  anguli  scapulas,  and  rhomboidei;  and,  at  times, 
also  over  a  well-developed  pectoralis.  On  the  other  hand,  an  in- 
filtration of  lesser  degree  than  actually  exists  may  be  diagnosed 
when  these  same  muscles  and  the  subcutaneous  tissue  overly- 
ing them  have  wasted.  This  is  most  pronounced  when  the  wast- 
ing is  a  reflex  trophic  change.  At  times,  from  reflex  trophic 
changes,  the  soft  parts  on  one  side  of  the  chest  will  be  reduced 
fully  one-third  in  mass  as  compared  with  the  same  muscles  and 


EXTENSIVE   INFILTRATION  487 

subcutaneous  tissue  on  the  other  side.  The  effect  of  this  upon 
the  data  derived  by  percussion  is  considerable. 

The  first  extensive  infiltration  is  very  often  in  the  lung  op- 
posite to  the  one  which  was  the  seat  of  the  original  focus ;  con- 
sequently the  condition  of  the  soft  tissues  is  extremely  impor- 
tant. Over  the  lung  with  the  old  lesion,  there  is  wasting  of 
varying  extent  and  varying  degrees,  while  over  the  area  of  the 
newer  infiltration,  unless  it  has  existed  for  many  months,  there 
is  increased  tone   (spasm)   of  the  muscles. 

Bearing  all  these  alterations  in  mind,  and  they  are  extremely 
important  in  advanced  tuberculosis,  we  find  the  following  condi- 
tions on  percussion  in  extensive  infiltration. 

If  the  tubercles  are  scattered  over  a  considerable  lung  area, 
but  not  thickly  set,  they  do  not  cause  the  amount  of  thickening 
of  the  tissue  necessary  to  produce  marked  dullness;  but  inter- 
fere with  the  normal  elasticity,  jcause  more  or  less  relaxation 
of  the  pulmonary  parenchyma  and  produce  a  note  tympanitic  in 
character. 

If  the  infiltration  is  more  dense  and  particularly  if  the  infec- 
tion is  of  such  virulence  as  to  produce  much  exudation  in  the 
tissues,  then  we  have  varying  degrees  of  dullness  according  to 
the  mass  and  virulence  of  the  infiltration  and  the  character  of 
the  exudation,  leading  up  to  the  flatness  of  caseous  pneumonia; 
and  varying  degrees  of  resistance  to  the  finger  reaching  its 
maximum  also  in  those  cases  which  show  the  thickest  studding 
of  tubercles  and  the  greatest  amount  of  exudation. 

One  condition  which  is  extremely  confusing  is  an  infiltration 
which  takes  place  in  the  second  lung  when  it  has  been  the  seat 
of  a  high  degree  of  compensatory  emphysema  because  of  a  wide- 
spread destructive  process  in  the  other  lung.  Here  the  funda- 
mental findings  on  percussion  are  those  of  emphysema, — in- 
creased resonance  and  decreased  resistance  to  the  finger  as  com- 
pared with  the  normal.  If  the  tension  is  extreme,  however,  and 
the  chest  bulging  and  the  intercostal  muscles  stretched,  the  note 
may  be  somewhat  tympanitic  or  dull  and  there  may  be  a  sense 
of  increased  resistance  to  the  finger.  This  condition,  while 
readily  detected  by  the  expert  examiner,  at  times  proves  con- 
fusing to  those  of  less  experience.     It  can  readily  be  seen  that 


488        PHYSICAL  EXAMINATION   IN   PULMONARY   TUBERCULOSIS 

infiltrations  of  slight  or  even  moderate  degree,  when  existing  in 
such  an  emphysematous  lung,  might  be  overlooked  on  percus- 
sion, being  overshadowed  by  the  findings  due  to  the  underlying 
emphysema. 

Infiltrations  underlying  thickened  pleura  are  extremely  dif- 
ficult to  make  out  on  percussion  because  of  the  changes  incident 
to  the  altered  pleura. 

Auscultation. — Auscultation  over  infiltrated  lung  tissue  shows 
a  variety  of  sounds.  Rales  may  or  may  not  be  present.  Ex- 
tensive infiltrations  may  exist  without  rales.  This  fact  is  not 
sufficiently  appreciated.  Too  much  dependence  in  diagnosis  is 
placed  upon  the  absence  or  presence  of  rales,  for  it  is  a  well 
established  fact  that  there  is  a  form  of  tuberculosis  of  low  viru- 
lence which  extends  over  wide  areas,  irritating  the  cells  and 
causing  new  tissue  formation,  the  entire  process  taking  place 
without  any  marked  exudation  accompanying  it,  or  without  ul- 
ceration and  loss  of  tissue.  Auscultation  over  such  areas  shows 
a  respiratory  note  often  somewhat  weakened;  harsher  than 
normal,  and  usually  accompanied  by  a  prolongation  of  the  ex- 
piratory note.  Eoughness  is  also  a  frequent  characteristic  if 
activity  is  present. 

If  the  process  is  more  virulent,  other  pathological  changes  oc- 
cur. The  bacilli  multiply,  necrosis  occurs,  toxins  diffuse  into 
adjacent  structures,  and  exudation  takes  place.  Such  infil- 
trated areas  show,  on  auscultation,  aside  from  the  characteristic 
harshness,  roughness,  prolongation  of  expiration,  and  a  variety 
of  accompanying  rales.  These  may  be  fine,  medium  or  coarse; 
dry  or  moist,  according  to  the  conditions  surrounding  their  pro- 
duction. 

Fibrosis. — Fibrosis  occurs  in  tuberculosis  when  the  infecting 
bacilli  are  of  a  low  grade  of  virulence.  It  is  a  result  of  irrita- 
tion whereby  the  tissues  are  stimulated  to  new  growth.  The 
cells  multiply  and  the  tissues  thicken,  increasing  their  density. 
Healing  in  tuberculosis  results  in  the  formation  of  fibrous  tis- 
sue. "When  ulceration  has  occurred,  however,  other  conditions 
will  also  be  present.  The  formation  of  fibrous  tissue  is,  as  a 
rule,  a  slow  process,  and  the  changes  found  on  inspection,  pal- 
pation and  percussion  are  much  the  same  as  those  of  long-stand- 


FIBROSIS  489 

ing  infiltration.  Consequently  inspection  and  palpation  show 
the  degenerative  changes  in  the  muscles  and  subcutaneous  tis- 
sue, often  with  diminished  motion  of  the  side.  Increased  density 
is  also  noted  by  palpating  over  the  fibroid  areas;  and,  if  the 
process  is  extensive,  a  compensatory  emphysema  is  usually  pres- 
ent in  other  portions  of  the  lungs  not  involved  in  the  fibrosis 
which  affords  a  decreased  resistance  to  the  palpating  fingers. 

Percussion  shows  a  higher  pitched  note  with  a  degree  of  dull- 
ness and  increased  resistance  to  the  finger  which  are  com- 
mensurate with  the  amount  of  fibrosis  present;  and  a  note  more 
resonant  than  normal  with  lessened  resistance  to  the  finger  over 
the  portions  of  lung  tissue  which  are  the  seat  of  compensatory 
emphysema  when  this  is  present. 

Auscultation  reveals  varying  degrees  of  harshness,  often  high 
pitched  in  character,  with  prolonged  and  often  high  pitched  ex- 
piratory note.  The  latter  is  often  of  a  blowing  character  and 
may  simulate  cavity.  A  point  of  differential  value  is  that  the 
blowing  expiration  in  the  presence  of  cavity  is  usually  lower  in 
pitch  than  the  inspiratory  note  while  that  which  accompanies 
fibrosis  is  higher.  The  note  over  fibrosis  may  also  be  accom- 
panied by  adventitious  sounds.  Sometimes  these  arise  in  the 
pleura,  sometimes  in  the  fibrous  tissue  itself  and  at  times  in 
the  muscles. 

Cavity. — Cavity  results  from  caseation  and  rupture  of  tuber- 
cles. Cavities  may  be  as  small  as  pinheads  or  so  large  that  they 
occupy  an  entire  lobe  or  entire  lung.  At  times  no  single  large 
cavity  but  many  small  ones  are  present.  Often  several  large 
communicating  cavities  exist.  Cavities  may  have  smooth  dry 
walls  or  they  may  be  ragged  and  secreting.  The  more  chronic 
cavities,  as  a  rule,  have  the  smoothest  walls.  Cavities  may  be 
surrounded  by  scar  tissue,  or  infiltrated  tissue  in  any  stage  of 
pathological  change  to  which  tubercles  are  subject.  The  same 
cavity  may  at  one  time  contain  secretion,  at  another  be  empty. 
It  can  readily  be  seen  that  these  various  conditions  cannot  pro- 
duce the  same  physical  signs.  Often  one  sign  will  be  present  on 
one  examination  and  be  absent  at  another.  This  must  be  under- 
stood in  order  to  avoid  confusion.  The  history  is  of  great  value 
in  determining  whether  or  not  cavities  are  to  be  suspected.    From 


490        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

history  alone  one  can  usually  determine  whether  loss  of  tissue 
is  to  be  suspected.  Fever,  accompanied  by  cough  and  free  ex- 
pectoration, has  nearly  always  been  present  at  some  previous 
time,  even  if  not  at  the  time  of  examination,  if  cavity  is  to  be 
suspected.  If  the  patient  is  expectorating  more  than  20  to  30 
c.c.  of  sputum,  unless  an  acute  or  chronic  simple  bronchitis  is 
present,  cavity  is  to  be  suspected.  In  chronic  cases  where  heal- 
ing is  occurring  cavities  may  be  found  when  the  amount  of 
sputum  is  decidedly  small. 

Inspection. — There  are  times  when  the  musculature  and  sub- 
cutaneous tissue  on  the  front  of  the  chest  have  wasted  to  a 
marked  degree  and  superficial  cavities  may  be  suspected  by  the 
sinking  in  of  the  soft  parts  during  inspiration.  This,  however, 
is  not  sufficiently  reliable  for  diagnosis. 

Palpation. — Loss  of  tissue  can  often  be  readily  detected  on 
light  touch  palpation.  In  palpating  over  a  tuberculous  lung, 
infiltrated  areas  will  be  recognized  by  a  degree  of  resistance  to 
the  finger,  which  is  greater  than  normal.  If  a  cavity,  or  several 
cavities  are  present  which  are  alone  or  together  sufficiently  large 
to  represent  a  considerable  loss  of  lung  tissue,  they  are  detected 
by  an  area  of  decreased  resistance  noted  by  the  palpating  finger 
in  the  midst  of  the  increased  resistance  which  belongs  to  the 
surrounding  infiltration.  I  have  learned  to  rely  on  this  sign — 
a  resistance  less  than  normal  noted  on  palpation  in  an  area  sur- 
rounded by  resistance  greater  than  normal — as  being  the  most 
constant  evidence  of  loss  of  pulmonary  tissue.  This  sign  is  pres- 
ent whether  there  is  one  large,  or  many  small,  or  several  com- 
municating cavities.  It  is  also  present  at  all  times  unless  the 
cavity  be  filled  with  secretion. 

Percussion. — Percussion  over  cavities  shows  several  changes 
from  the  note  elicited  over  surrounding  tissues.  It  may  be  im- 
paired, more  resonant,  tympanitic,  or  the  pitch  may  be  lower, 
or  it  may  show  the  "cracked  pot"  or  Wintrich  phenomena.  The 
character  of  the  note  depends  much  on  the  force  of  the  percus- 
sion blow.  There  is  no  particular  percussion  sound  or  phenon- 
enon  that  is  found  with  regularity  over  cavities.  Increased 
resonance  results  from  the  loss  of  tissue  and  can  usually  be 
elicited,  if  the  stroke  is  not  too  forceful  and  the  cavity  is  suf- 


CAVITY  491 

ficiently  large.  The  note,  however,  is  modified  greatly  by  sur- 
rounding tissue,  so  the  sound  which  particularly  belongs  to  the 
cavity  can  best  be  elicited  by  a  light  stroke. 

To  my  mind  the  most  characteristic  note  found  over  areas  of 
excavation  which  are  surrounded  by  infiltration,  is  a  "dull 
tympany"  elicited  on  a  stroke  of  moderate  force. 

"Cracked  pot"  may  be  heard  over  superficial  cavities  with 
smooth  walls  waen  freely  communicating  with  a  bronchus.  Most 
definite  "cracked  pot"  sounds  may  be  heard  at  one  examination 
and  be  absent  at  another  a  few  hours  later,  because  of  a  closure 
of  the  cavity  opening.  Wintrich  pointed  out  that  the  tympany 
over  cavity  assumes  a  higher  pitch  when  the  mouth  is  open.  An 
absence  of  these  signs  must  not  be  taken  as  having  any  bearing 
on  the  presence  of  cavity.  Resonance  over  cavity  is  sometimes 
relatively  greater  because  of  marked  wasting  of  soft  tissues 
(muscles  and  subcutaneous  tissues)  which  would  otherwise  add 
a  dull  character  to  the  note. 

The  lack  of  resistance  to  the  finger  is  of  greater  importance 
than  the  character  of  the  percussion  note.  The  increased  resist- 
ance noted  over  thn  infiltrated  area  will  be  absent  where  excava- 
tion has  occurred,  as  mentioned  under  palpation.  This  condition 
in  the  midst  of  dullness  can  mean  but  one  thing — a  lack  of  tis- 
sue underlying,  and  while  this  might  be  due  to  a  dilated  bronchus 
or  a  circumscribed  pneumothorax  as  a  rule  it  means  cavity. 

Auscultation. — Auscultation  over  cavities  may  reveal  un- 
doubted proof  of  their  existence  or  questionable  or  negative  in- 
formation. Where  the  examiner  has  been  listening  at  frequent 
intervals  over  a  considerable  period  of  time  over  areas  the  seat 
of  widespread  infiltration  and  caseation,  he  will  now  and  then 
find  that  the  rales  have  suddenly  disappeared  and  the  sounds 
have  become  clearer.  This  does  not  mean  that  the  tubercles  have 
become  less  active  and  that  collateral  inflammation  has  disap- 
peared and  that  cicatrization  is  progressing;  but  it  means  that 
the  tissue  has  sloughed  out  leaving  a  cavity  behind.  An  acute 
cavity  may  be  suspected  at  times  on  this  finding  alone. 

Chronic  cavities  may  also  be  suspected  by  an  absence  of  rales 
in  the  presence  of  large  quantities  of  sputum.  If  the  sputum 
comes  from  disseminated  areas  of  infiltration  and  necrosis  in  the 


492        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

pulmonary  tissue,  medium  and  large-sized  rales  will  be  heard  in 
abundance  over  the  entire  area  affected;  but,  if  the  tissues  are 
free  from  rales,  this  shows  that  the  sputum  must  come  from 
elsewhere,  a  cavity  or  cavities,  empyema  with  bronchial  fistula 
being  the  only  alternative.  Not  infrequently  do  we  find  patients 
suffering  from  chronic  inactive  tuberculosis  who  expectorate 
50  to  100  c.c.  of  sputum  daily,  but  who  show  few  rales  on  exami- 
nation. On  the  contrary  coarse  bubbling  rales,  localized  and  per- 
sistent, often  suggest  cavity.  These  may  be  metallic  in  charac- 
ter, particularly  if  the  cavity  is  large  and  possessed  of  smooth 
walls. 

If  cavities  are  superficial  and  covered  by  thickened  pleura,  or 
if  they  are  surrounded  by  scar  tissue,  aside  from  the  rales  which 
originate  -within  the  cavity,  many  adventitious  sounds  are  at 
times  heard.  These  may  simulate  medium  rales,  but,  as  a  rule, 
are  dry  in  character  and  heard  both  on  inspiration  and  expira- 
tion. 

The  breath  sounds  heard  over  cavity  may  be  changed  very 
little,  if  any,  from  those  over  the  surrounding  tissue.  Some- 
times the  sounds  are  diminished,  this  particularly  when  some 
interference  with  the  ingress  of  air  exists. 

Blowing  expiration  is  frequently  found  over  cavities,  but  is 
not  pathognomonic.  This  character  of  breathing  is  also  found 
at  times  over  scar  tissue,  particularly  near  the  apex.  I  am  in- 
fluenced very  much  in  my  decision  as  to  whether  the  blowing  is 
due  to  cavity  or  scar  tissue  by  the  relative  pitch  of  the  inspira- 
tory and  expiratory  sounds.  If  expiration  is  higher  pitched 
than  inspiration  the  blowing  is  most  apt  to  be  due  to  fibrosis;  if 
it  be  lower  pitched  it  suggests  cavity. 

Amphoric  breathing  is  occasionally  found,  but  only  in  a  small 
percentage  of  cases;  and  only  at  times  in  these.  A  peculiar  dis- 
tinct echo  on  coughing  is  sometimes  transmitted  to  the  stetho- 
scope. While  this  is  not  regularly  heard,  it  is  characteristic  of 
cavity. 

A  study  of  whispered  voice  transmission  helps  to  detect  cavity. 
Such  syllables  as  "one,"  "two,"  "three,"  "ha,"  "ha,"  or  "whis- 
per-r-r-r"  are  more  distinctly  transmitted  as  syllables  over  cav- 
ity than  over  infiltration  or  fibrosis,  and  when  considered  in  con- 


COMPENSATORY   EMPHYSEMA  493 

junction  with  other  signs  are  of  value  in  diagnosis.  A  cavity 
large  enough  to  give  signs  must  be  about  as  large  as  a  walnut. 
Several  smaller  ones  in  groups,  however,  may  be  detected.  As 
a  result  of  the  compensatory  changes  within  the  thorax  small 
cavities  may  be  compressed  and  disappear;  and  large  ones  may  be 
so  compressed  as  to  completely  alter  the  signs  and  symptoms 
caused  by  them.  An  alteration  or  disappearance  of  signs  after 
once  being  found  must  not  be  taken  as  indicating  that  the  pre- 
vious findings  were  incorrect. 

Compensatory  Emphysema. — Compensatory  emphysema  is  a 
part  of  practically  every  advanced  case  of  pulmonary  tubercu- 
losis that  reaches  the  stage  of  loss  of  tissue,  whether  through 
new  tissue  formation  and  contraction,  or  through  destruction 
and  cavity  formation.  I  look  upon  it  as  being  an  expression  of 
nature's  attempt  to  equalize  the  atmospheric  pressure  within 
the  lung  and  that  upon  the  surface  of  the  chest  as  described 
more  fully  on  page  282. 

Compensatory  emphysema  is  a  dilatation  of  the  air  cells.  In 
tuberculosis  it  affects  the  tissues  which  are  most  free  from 
infection,  those  which  are  most  useful  to  the  patient.  Where 
one  lobe  is  the  seat  of  cavity  or  marked  fibrosis,  a  marked  de- 
gree of  compensatory  emphysema  will  usually  be  distributed 
over  a  considerable  portion  of  the  remaining  pulmonary  tissue. 
If  both  upper  lobes  are  the  seat  of  destructive  change,  the  bases 
are  emphysematous ;  and  if  one  entire  lung  is  involved  in  the  de- 
structive process  the  other  lung  becomes  emphysematous.  Em- 
physema distorts  the  lobes  and  displaces  their  boundaries,  as 
illustrated  in  Fig.  40,  page  286. 

This  condition  is  sometimes  spoken  of  as  an  hypertrophy  of 
the  lung,  rather  than  an  emphysema.  It  is  not  primarily  an 
emphysema  in  the  sense  that  it  is  a  degeneration  of  the  alveolar 
walls,  neither  is  it  an  hypertrophy  in  the  sense  of  it  being  an 
increase  in  tissue,  such  as  we  see  in  the  heart  muscle  for  in- 
stance. I  very  much  doubt  if  it  is  wholly  what  we  have  taught — 
an  enlargement  of  that  portion  of  the  lung  which  is  still  able  to 
functionate  as  a  result  of  nature's  effort  to  compensate  for  the 
parts  destroyed — but  look  upon  it  as  a  compensatory  enlargement 
of  pulmonary  tissue  in  order  to  fill  the  thoracic  cavity.     It  oc- 


494        PHYSICAL  EXAMINATION  IN  PULMONARY  TUBERCULOSIS 

curs  in  consequence  of  an  attempt  to  preserve  an  equilibrium  be- 
tween the  atmospheric  air  as  it  presses  upon  the  surface  of  the 
chest  and  as  it  presses  on  the  air  cells  from  within  through  the 
trachea  and  bronchi.  The  result  is  a  dilatation  which  to  all  ap- 
pearances is  an  emphysema.  The  extra  work  thrown  upon  it  is 
due  to  the  loss  of  tissue,  but  it  is  not  a  cause  of  the  dilatation  of 
the  air  cells.  If  the  compensatory  change  is  to  be  looked  upon  as 
an  attempt  on  the  part  of  the  lung  to  better  carry  out  its  func- 
tion, the  emphysema  is  a  mistake  because  the  dilated  air  cells  are 
not  functionally  as  capable  as  the  normal  cells. 

Inspection. — It  can  readily  be  understood  that  compensatory 
emphysema,  with  its  distended  air  cells  and  its  pressure  on  sur- 
rounding structures,  will,  if  well  marked,  cause  alterations  in 
motion  and  bulging  of  the  thoracic  walls  from  which  its  presence 
may  be  suspected.  If  of  slight  degree  no  change  may  be  noted 
on  inspection. 

By  carefully  inspecting  a  chest  which  is  the  seat  of  marked 
compensatory  emphysema  one  can  often  form  a  fairly  accurate 
impression  of  the  pathological  changes  within  the  lungs.  In 
generalized  emphysema  in  lungs  which  are  not  the  seat  of 
destructive  processes,  the  anteroposterior  diameter  of  the  chest 
increases,  the  lower  ribs  become  elevated,  the  costal  angle  wid- 
ens, the  diaphragm  becomes  displaced  downward,  and  the  mo- 
tion of  the  thoracic  walls  is  decreased.  Compensatory  emphy- 
sema on  the  other  hand  is  confined  to  limited  portions  of  pul- 
monary tissue,  because  there  is  a  decrease  in  the  total  pulmonary 
area.  The  air  cells  which  are  not  destroyed  are  involved  in 
the  emphysema.  They  are  dilated,  and  yet,  in  spite  of  this,  they  are 
compelled  to  aerate  the  blood.  Consequently,  all  inspiratory  effort 
is  directed  toward  the  emphysematous  areas  as  being  the  parts 
which  are  not  destroyed;  consequently  these  portions  of  the  chest 
often  take  upon  themselves  an  increased  movement.  Localized 
areas  of  bulging  with  increased  motion  are  very  suggestive  of 
compensatory  emphysema.  When  one  lung  is  the  seat  of  marked 
destruction  and  the  other  is  markedly  emphysematous,  the  aux- 
iliary muscles  of  respiration  are  called  upon  for  extra  work 
and  so  stand  out  plainly  on  inspection.  This  is  particularly  true 
of  the  sternocleidomastoideus  and  scaleni.    Under  such  circum- 


COMPENSATORY   EMPHYSEMA  495 

stances,  too,  we  sometimes  see  the  supraclavicular  fossa  swell 
up  on  forcible  cough.  One  must  not  mistake  the  increased  tone  in 
the  neck  muscles  in  the  presence  of  emphysema  for  reflex  muscle 
spasm., 

Palpation. — Palpation  over  areas  of  compensatory  emphysema 
shows  tense  intercostals,  increased  tension  of  that  portion  of 
the  lung  affected,  and  usually  increased  movement.  The  total 
density,  as  determined  by  the  resistance  to  the  palpating  finger, 
is  less  than  normal,  where  the  pleura  is  normal  and  less  than 
would  be  expected  where  covered  by  thickened  pleura,  or  where 
previously  or  secondarily  the  seat  of  infiltration.  Palpation 
shows  the  borders  of  the  emphysematous  lung  to  be  pushed  out- 
ward. Many  times  the  diaphragm  and  mediastinum  are  pushed 
far  from  their  normal  position,  as  described  on  pages  285  and  305. 

Percussion. — Percussion  shows  hyperresonance,  and  where  in- 
trapulmonary  tension  is  high,  tympany;  although  these  sounds 
are  greatly  modified  by  other  conditions  present,  such  as  thick- 
ened pleura  and  infiltrations.  Lessened  resistance  is  also  pres- 
ent, less  than  that  over  normal  lung  when  neither  infiltration 
nor  thickened  pleura  are  present. 

Auscultation. — Emphysema  shows  many  changes  in  the  re- 
spiratory sounds.  Sometimes  the  note  is  weak;  but  this  is  more 
apt  to  be  the  case  in  generalized  emphysema  than  in  the  com- 
pensatory form.  When  the  note  is  weak  in  compensatory  emphy- 
sema it  is  usually  because  of  thickened  pleura,  for  the  note  is 
usually  exaggerated  because  of  the  extra  work  thrown  upon 
the  part. 

The  characteristics  of  the  respiratory  sound  in  compensatory 
emphysema  are  a  roughened  inspiratory  note  which  often  par- 
takes of  or  gives  way  to  a  harshness  as  the  inspiratory  effort 
becomes  more  intense  and  the  note  becomes  more  exaggerated; 
and  a  prolongation  of  the  expiratory  note  due  to  the  slowness 
with  which  the  emphysematous  lung  completes  the  expiratory 
phase.  The  prolonged  nature  of  the  expiratory  note  is  often 
overlooked  by  not  listening  intently  through  the  entire  expira- 
tory phase  of  respiration. 

It  has  often  seemed  to  me  like  the  contraction  of  the  tense 
thoracic  muscles  has  much  to  do  with  the  character  of  the  in- 
spiratory note  in  this  affection.     In  this  connection  Kingston 


496        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

Fowler2  states,  in  discussing  emphysema  in  general:  "In  place 
of  tliis  normal  vesicular  murmur  audible  on  inspiration,  the 
continuous  low  pitched  rumbling  sound  produced  by  the  con- 
traction of  the  muscles  is  very  distinct." 

Dry  Pleurisy. — Dry  pleurisy  is  a  frequent  accompaniment  of 
advanced  tuberculosis.  It  comes  at  times  as  a  localized  process 
accompanying  an  area  of  caseation  near  the  pleural  surface; 
again,  it  manifests  itself  as  an  acute  inflammation  more  or  less 
widespread  involving  the  subpleural  tissues  or  pleural  surfaces. 
Either  process  may  result  in  adhesions. 

Inspection. — A  marked  limitation  of  movement  on  the  side  of 
the  inflammation  is  usually  evident  to  the  eye,  particularly  if 
the  process  is  near  the  bases. 

Palpation  usually  detects  an  increased  tone  (spasm)  of  the  in- 
tercostal muscles  which  often  feel  decidedly  boardy.  It  may  also 
detect  a  pleural  rub.  It  likewise  confirms  the  limited  motion  noted 
on  inspection. 

Percussion  is  practically  valueless. 

Auscultation  will  reveal  moist  rales  over  the  pulmonary  focus 
when  the  pleurisy  is  due  to  active  caseation  of  a  subpleural  pul- 
monary focus.  It  will  also  detect  a  pleural  rub  or  roughness  when 
the  surfaces  of  the  pleura  are  inflamed.  A  grating  sound  may  be 
heard  at  times  for  some  time  after  the  acute  symptoms  disappear. 
Pain  is  usually  a  symptom  and  of  itself  is  often  sufficient  for  diag- 
nosis. 

Pleural  Effusion. — Pleural  effusion  now  and  then  complicates 
advanced  tuberculosis.  This  complication  is  found  comparatively 
infrequently  in  patients  who  are  cared  for  properly.  It  seems 
that  there  is  something  in  the  general  tonic  treatment  especially 
when  fortified  by  tuberculin  that  makes  effusions  rare.  The  symp- 
toms and  physical  signs  vary  with  the  size  of  the  effusion. 

Inspection. — Effusions  when  large  may  be  suspected  or  even  di- 
agnosed by  the  bulging  ribs  and  interspaces  on  inspection.  Dys- 
pnea may  be  present.  The  bulging  of  the  ribs,  limited  motion, 
and  displacement  of  the  heart  to  the  opposite  side  in  the  absence 
of  symptoms  pointing  to  pneumothorax,  suggest  effusion. 

Palpation. — Palpation  shows  increased  resistance  over  the  fluid 


2Allbutt-Rolleston:     System  of  Medicine,  vol.  v,  1909,  Macmillan  Company,  Ltd.,  New 
York. 


PLEURAL  EFFUSION  497 

due  partly  to  the  increased  tension  of  the  intereostals  and  partly 
to  the  increased  density  caused  by  the  fluid.  The  outlines  of  the 
fluid  can  be  detected  by  light  touch  palpation  as  readily  as  by 
percussion.  Voice  transmission  as  determined  by  palpation  and 
auscultation  is  diminished.  Palpation  also  confirms  the  limita- 
tion of  motion  on  the  side. 

Percussion. — Percussion  may  show  any  condition  from  a  slightly 
impaired  note  to  a  very  dull  one.  It  also  reveals  increased  re- 
sistance to  the  finger.  The  data  obtained,  however,  requires  con- 
firmation and  must  be  considered  in  conjunction  with  that  ob- 
tained by  other  methods  of  examination.  Groco's  sign,  which  is 
a  triangular  area  of  dullness  on  the  side  opposite  the  effusion,  is 
usually  found,  if  looked  for  with  sufficient  diligence.  It  is  most 
pronounced  and  easiest  of  detection  when  the  effusion  is  large. 

Auscultation. — The  data  obtained  on  auscultation  over  the  ef- 
fusion may  be  nothing  more  than  a  weakened  respiratory  note; 
but  this  is  of  value  in  conjunction  with  other  data.  There  is  apt 
to  be  an  exaggerated  note  over  the  pulmonary  tissue  above  if  the 
effusion  is  large. 

Thickened  Pleura. — The  pleura  may  show  any  degree  of  thick- 
ening from  one  that  is  barely  recognizable  to  one  of  several  centi- 
meters. This  is  an  extremely  common  condition  in  pulmonary 
tuberculosis.  It  is  rarely  that  we  find  apical  pleurae  free;  for,  as 
the  disease  affects  the  surface  of  the  lung  the  irritation  extends 
to  the  pleural  surfaces  and  adhesions  and  thickenings  result.  Ad- 
hesions are  favored  at  the  apex  by  the  limited  motion  of  the  part. 
Likewise  they  are  opposed  at  the  bases  by  the  extensive  movement. 
When,  through  disease  in  the  underlying  lung  or  of  the  pleura 
itself,  the  respiratory  movements  are  greatly  limited,  adhesions 
are  favored.  After  adhesions  have  once  taken  place  increased 
thickening  is  probably  favored  by  the  irritation  resulting  from  the 
movements  of  the  thoracic  wall  and  their  pull  against  the  adherent 
pleurae. 

Inspection. — Inspection  usually  shows  a  limited  motion  which 
is  most  marked  when  the  thickening  extends  to  the  base;  but  this 
differs  in  no  way  recognizable  on  inspection  from  limited  motion 
from  other  causes,  except,  at  times,  the  side  seems  to  move  as  a 


498         PHYSICAL   EXAMINATION   IN   PULMONARY   TUBERCULOSIS 

unit.     The  wasting  of  the  soft  tissues  over  areas  of  thickened 
pleura  of  long  duration  is  often  plain  to  the  eye. 

Palpation. — Palpation  gives  the  most  reliable  information  that 
we  have  in  determining  thickened  pleura.  It  not  only  confirms 
the  lack  of  motion  but  it  reveals  an  increased  density  of  the  pal- 
pated tissues  varying  with  the  degree  of  thickening,  and  shows 
by  the  peculiar  characteristics  of  the  soft  tissues  (skin,  subcuta- 
neous tissue,  and  muscles)  overlying  the  pleura  that  there  is  a 
pathological  condition  underlying.  Degenerative  changes  take 
place  in  the  overlying  muscles  as  described  by  Coplin3  which 
give  very  valuable  diagnostic  data  on  palpation.  (See  Volume 
II,  Chapter  XXV.)  The  soft  tissues  overlying  the  thickened  pleura 
lose  their  elasticity  and  feel  lifeless  and  doughy.  The  tissues 
feel  to  the  touch  somewhat  like  those  affected  by  a  very  slight 
edema.  Later  the  subcutaneous  tissue  and  intercostals  degenerate 
and  at  times  contraction  takes  place,  drawing  the  intercostal  spaces 
nearer  together.  Bonniger4  has  described  a  unilateral  lymph-stasis 
as  affecting  the  skin,  subcutaneous  tissue,  and  muscles  over  dis- 
eased pleurse.  He  states  that  the  tissues  appear  to  be  increased 
in  volume  and  firmer  than  normal.  He  mistakenly  offered  this  as 
an  explanation  for  the  spasm  of  the  muscles  which  occurs  in  the 
presence  of  active  disease  in  the  pleura  and  lung.  In  this  he  un- 
doubtedly recognized  the  doughy,  inelastic,  lifeless  condition  which 
I  have  described. 

Percussion. — Percussion  alone  gives  nothing  distinctive  of  thick- 
ened pleura.  It  reveals  by  a  higher  pitched  note,  a  slightly  de- 
creased resonance  and  an  increased  resistance  to  the  finger  that 
there  is  an  increased  density  of  the  tissues  underlying.  "Which 
tissues  are  responsible  for  the  changes  can  only  be  determined  by 
considering  the  data,  together  with  that  obtained  by  other  methods 
of  examination. 

Auscultation. — Auscultation  over  thickened  pleura  will  show 
varying  degrees  of  diminished  breathing;  but  since  this  complica- 
tion is  usually  associated  with  infiltration  of  the  underlying  pul- 
monary tissue,  and  since  this  of  itself  often  causes  diminished 
breathing,  a  weakened  respiratory  note  must  not  necessarily  be 
considered  as  due  to  thickened  pleura.     Other  signs  such  as  those 


3Changes  in  the  Intercostal  Muscles  and  the  Diaphragm  in  Infective  Processes  Involv- 
ing the  Lungs  and  Pleura,  American  Journal  of  Medical  Sciences,  May,  1904. 

4B6nniger:  Ober  halbseitige  Lymphstauung  bei  Erkrankungen  des  Lunge  bzw.  Pleura, 
Berliner  klinische  Wochenschrift,  Nr.   25,  June  20,    1910. 


MEDIASTINAL  THICKENING  499 

determined  on  palpation  should  be  looked  for.  Sometimes  when 
the  pleura  is  thickened  there  are  many  adventitious  sounds  present 
which  accompany  both  phases  of  the  respiratory  act.  They  may 
sound  like  medium  rales,  but,  for  the  most  part,  are  dry  in  char- 
acter. They  are  apt  to  start  with  inspiration  and  continue  until 
the  end  of  expiration;  and  they  give  the  impression  of  being  near 
the  stethoscope.  Where  these  originate  is  not  definitely  settled 
but  we  are  safe  in  saying  that  they  originate  either  in  the  muscles 
or  tissues  which  make  up  the  thickened  pleura,  or  in  both. 

Mediastinal  Thickening. — The  mediastinum  is  a  region  which 
has  been  far  too  much  neglected  in  clinical  medicine.  Prior  to 
the  use  of  the  x-ray  it  was  considered  almost  impossible  to  diag- 
nosticate pathological  conditions  in  this  part  of  the  thoracic  cavity, 
except  they  were  of  the  most  evident  type.  But,  after  obtaining 
a  more  definite  idea  of  the  processes  which  affect  the  mediastinum 
most  commonly,  we  are  now,  clinically,  either  with  or  without  the 
aid  of  the  x-ray,  able  to  examine  this  field  with  a  fair  degree  of 
satisfaction. 

The  mediastinum  is  a  fruitful  field  for  study  in  tuberculosis  and 
particularly  in  advanced  tuberculosis.  It  at  times  shows  fibrous 
thickening  which  is  important  in  the  causation  of  symptoms  even 
when  the  disease  of  the  pulmonary  tissue  has  not  been  suspected. 
Enlargement  of  glands,  which  often  belongs  to  the  stage  prior 
to  the  pulmonary  involvement  persists  and  is  evident  on  careful 
examination  in  from  20  to  25  per  cent  of  cases.  Adami  and  Mac- 
Kea5  say  that  one-fourth  of  all  healed  cases  of  pulmonary  tuber- 
culosis show  enlarged  bronchial  glands.  That  type  of  tubercu- 
losis which  starts  at  the  hilus  and  extends  out  into  the  pulmon- 
ary tissue  really  belongs  primarily  to  the  mediastinum.  Tumor 
masses  of  non-tuberculous  nature,  either  solid  or  aneurism,  at 
times  complicate  tuberculosis  and  must  be  looked  for.  Aside 
from  these  thickenings,  the  shifting  of  the  mediastinum  is  ex- 
tremely important  and  deserves  careful  study.  (For  a  more 
complete  description  of  this  see  page  285. 

Fibrous  thickening  of  tissue  in  the  mediastinum  as  it  occurs  at 
times  in  advanced  pulmonary  tuberculosis,  in  my  experience,  is 
accountable  for  several  direct  symptoms,  differing  according  to 
the  nature  of  the  case. 


transactions  of  the  Sixth  International   Congress  for  Tuberculosis,    1908. 


500        PHYSICAL  EXAMINATION  IN  PULMONARY   TUBERCULOSIS 

In  a  few  cases  hoarseness  is  a  marked  symptom;  depending  on 
the  extent  to  which  the  laryngeal  nerves  are  irritated.  Cough, 
coming  on  in  asthmatic  paroxysms,  is  not  uncommon.  It  may 
have  a  brassy  tinkle.  Bronchitis  is  often  a  common  accompani- 
ment and  is  usually  of  a  stubborn  nature. 

Inspection. — As  a  rule  inspection  shows  nothing  definite  as  to 
thickening  which  occurs  within  the  mediastinum.  Occasionally, 
tumors,  if  large,  may  be  suspected,  by  bulging  of  the  thoracic 
wall. 

Palpation. — Palpation  and  percussion  are  our  most  valuable 
measures  in  diagnosis.  By  palpating  over  the  sternum  and  ver- 
tebral column  one  will  learn  the  usual  degree  of  resistance  which 
marks  the  normal  mediastinum ;  and  will  be  able  to  detect  any  in- 
creased resistance  due  to  pathological  changes. 

New  tissues,  when  present  in  the  mediastinum,  may  belong  to 
the  tissues  normally  there  or  to  pathological  processes  extending 
out  from  the  pulmonary  parenchyma;  and  the  findings  will  vary 
accordingly.  Anteriorly,  the  feelings  of  increased  resistance  will 
be  under  the  sternum  in  the  former  case,  while  they  will  push  out 
beyond  its  borders  in  the  latter.  It  is  well  after  palpating  the 
sternum,  to  commence  out  in  the  interspaces  and  gradually  ap- 
proach the  sternum,  then  repeat  the  same  over  the  ribs.  Any  re- 
sistance should  be  noted.  On  numerous  occasions  I  have  been  able 
to  suspect  pathological  deposits  of  fibrous  tissue  adjacent  to  the 
hilus  which  were  confirmed  by  the  x-ray,  simply  by  noting  the  de- 
parture from  the  normal  in  the  resistance  to  the  palpating  finger. 
Posteriorly,  by  straddling  the  spinous  process  with  the  first  and 
second  finger,  as  shown  in  Fig.  16,  page  115,  and,  beginning  above, 
palpating  downward,  one  will  learn  to  detect  abnormally  increased 
resistance,  if  present.  Usually,  if  due  to  peribronchial  and  peri- 
tracheal glands,  it  will  be  detected  at  the  level  of  the  third  dorsal 
vertebras.  This  increased  resistance  as  a  rule  continues  into  the 
heart  resistance,  which  normally  begins  in  the  average  adult  with 
the  sixth  dorsal.  The  resistance  is  nearly  always  greater  on 
the  right  than  on  the  left  side  of  the  spine  because  of  the  local- 
ization of  the  trachea  on  that  side.  It  must  not  be  forgotten,  how- 
ever, that  a  certain  amount  of  shifting  of  the  mediastinum  is  com- 
mon in  advanced  tuberculosis  and  that  it  affects  the  position  of  the 
glands. 


MEDIASTINAL   THICKENING  501 

Percussion. — Percussion  also  shows  the  increased  resistance  to 
the  finger  though  probably  it  is  not  as  sensitive  as  palpation.  Fred- 
erick T.  Roberts6  recognizes  the  value  of  resistance  in  percussion 
as  follows:  "It  is  highly  important  in  relation  to  mediastinal  tu- 
mors to  bear  in  mind  when  carrying  out  the  method  of  percus- 
sion, not  only  the  sounds  which  are  elicited,  but  also  the  sensa- 
tions which  are  felt  by  the  fingers  during  the  act.  Not  un- 
commonly the  latter  afford  most  valuable  information."  Per- 
sonally, while  practicing  both,  I  deem  the  resistance  of  greater 
value.  Percussion  over  mediastinal  thickenings  will  usually  show 
an  impaired  note.  It  may  be  of  any  degree  of  dullness  or  even 
flat,  according  to  the  amount  and  nature  of  the  tissue  present. 

John  C.  da  Costa,  Jr.,7  in  a  careful  study  of  dorsal  percus- 
sion in  enlarged  tracheobronchial  glands,  states  that  in  18  cases 
carefully  studied  he  found  the  following  four  groups  of  physical 
signs : 

1.  Interscapular  dullness,  above  the  level  of  the  inferior  scapu- 
lar angles,  or  over  the  first  seven  thoracic  spinous  processes.  To 
this  group  belonged  twelve  or  two-thirds  of  the  cases. 

2.  Infrascapular  dullness,  below  the  level  of  the  inferior  scapu- 
lar angles,  or  over  one  or  more  of  the  five  lower  spinous  tips.  To 
this  group  belonged  two  cases. 

3.  General  thoracic  hyperresonance  over  the  entire  thoracic 
segment.     To  this  group  belonged  three  cases. 

4.  Normal  percussion  signs  in  the  entire  thoracic  segment.  To 
this  group  belonged  one  case. 

From  this  study  it  can  be  seen  that  sound  alone  is  not  the  best 
criterion  by  which  to  judge  of  the  presence  or  absence  of  enlarged 
mediastinal  glands. 

Auscultation. — Auscultation  is  of  little  value  in  diagnosis  ex- 
cept in  cases  where  the  new  tissue  is  of  such  a  nature  as  to  con- 
strict a  bronchus,  in  which  case  weakened  breathing  in  the  part 
affected  may  be  detected,  or  where  the  enlargements  stand  in  such 
relationship  to  the  chest  wall  as  to  cause  increased  transmission  of 
the  breath  sounds. 


'Mediastinal   New   Growth,    Allbutt-Rolleston:      System   of    Medicine,    vol.    v,    1909. 
'Dorsal  Percussion  in  Enlargements  of  the  Tracheobronchial  Glands,  American  Journal 
of  the  Medical  Sciences,  November,  1913. 


CHAPTER  XVni. 
TUBEECULIN  TESTS  IN  DIAGNOSIS. 

General  Considerations. — Now  that  we  have  at  our  command 
several  different  methods  of  making  the  tuberculin  test,  and  are 
gradually  learning  their  limitations,  we  have  arrived  at  a  place 
where  we  can  state  with  increased  definiteness  the  value  of 
these  measures. 

Years  ago,  when  the  diagnostic  value  of  tuberculin  was  first 
learned,  the  subcutaneous  was  the  only  tuberculin  test  known. 
It  was  believed  that  a  reaction  to  a  dose  of  10  mgs.  or  less  of 
Koch's  Old  Tuberculin  was  positive  evidence  of  the  presence  of 
clinical  tuberculosis;  and  that  a  failure  to  react  to  10  mgs.  at 
least,  if  it  were  repeated  once  later,  was  a  definite  sign  that  tu- 
berculosis was  not  present.  At  that  time  the  frequency  of  tuber- 
culous infections  as  we  know  it  today  was  not  known. 

A  great  prejudice  against  the  use  of  tuberculin  as  a  diag- 
nostic measure  soon  arose  because  of  the  severe  reactions  which 
attended  it;  so,  the  tuberculin  test  did  not  make  great  headway 
until  other  forms  of  employing  it  were  discovered. 

In  1907  von  Pirquet  announced  the  cutaneous  test.  This  was 
soon  followed  by  the  announcements  of  Wolff-Eisner  and  Cal- 
mette,  of  the  conjunctival  test,  by  Moro  of  the  percutaneous,  and 
by  Manteaux  of  the  intradermal.  While  other  forms  have  also 
been  suggested ;  yet  these  are  the  ones  which  have  been  employed 
to  the  greatest  advantage.  They  have  helped  greatly  to  popu- 
larize the  use  of  tuberculin  in  diagnosis,  although  they  have  also 
added  considerable  confusion  on  account  of  the  different  opin- 
ions as  to  interpretation. 

When  the  cutaneous  test  was  applied  generally  to  children  it 
was  found  that  a  very  large  proportion  of  them  reacted  promptly. 
It  shows  that  most  children  are  already  infected  with  tubercu- 
losis by  the  time  they  reach  their  fifteenth  year.     This  fact  has 


TUBERCULIN    TESTS  503 

caused  great  confusion  and  challenged  the  worth  of  all  tuber- 
culin reactions  in  adults,  though  I  believe  unjustly. 

All  tuberculin  reactions,  except  the  general  reaction,  are  anti- 
gen-antibody or  immunity  reactions.  The  general  reaction,  on 
the  other  hand,  is  a  toxic  reaction  as  described  more  fully  in 
Volume  II,  Chapter  XL.  Immunity  reactions  are  an  expres- 
sion of  the  reaction  which  occurs  between  the  specific  ferments 
or  antibodies  which  are  called  into  being  as  a  result  of  the  stimu- 
lation of  the  body  cells  by  the  tuberculin  introduced  into  the 
tissues.  Whenever  an  inoculation,  but  particularly  an  infection 
with  tubercle  bacilli  takes  place,  the  cells  of  the  body  of  that 
individual  are  so  changed  that  they  are  sensitized  against  fur- 
ther attacks  of  the  tubercle  bacillus  and  its  products;  conse- 
quently the  general  opinion  of  the  tuberculin  reaction  being  evi- 
dence of  active  tuberculosis  has  gradually  changed  and  in  the 
minds  of  most  clinicians  the  fact  that  an  adult  reacts  to  tuber- 
culin has  gradually  lost  its  significance.  This  change  in  atti- 
tude toward  the  tuberculin  tests  is  not  wholly  warranted;  but 
our  newer  knowledge  shows  that  reactions  must  be  more  care- 
fully interpreted.  While  a  tuberculin  reaction  will  occur  as 
long  as  the  cells  are  sensitized  to  the  products  of  the  tubercle 
bacillus  (as  long  as  specific  defense  is  present)  and  as  long  as 
they  are  active  in  producing  specific  antibodies  against  the  tuber- 
cle bacillus,  yet  there  is  a  recognized  difference  in  the  manner 
in  which  the  body  cells  respond  when  fighting  an  active  infec- 
tion as  compared  with  a  quiescent  or  healed  lesion.  Observa- 
tion has  led  me  to  believe  that  these  reactions  differ  greatly  and 
are  of  decided  value.  I  have  endeavored  to  interpret  reactions, 
particularly  the  skin  reaction,  according  to  certain  recognized 
principles  in  the  establishment  of  immunity,  and,  while  there  are 
many  times  when  it  will  not  give  the  desired  information,  yet 
it  will  help  as  often  as  most  measures  in  diagnostic  use. 

It  is  most  reliable  in  persons  whose  health  is  not  undermined, 
because  a  positive  reaction  depends  on  the  body  cells  having 
their  normal  reacting  capacity  and  being  able  to  respond  with 
specific  cell  sensitization  and  with  the  production  of  specific 
antibodies  when  brought  in  contact  with  the  tubercle  bacillus 
or  substances  derived  from  it.     The  body  cells  are  most  active 


504  TUBERCULIN   TESTS  IN   DIAGNOSIS 

in  defense  during  the  time  when  they  are  fighting  active  infec- 
tion, and  less  active  when  this  infection  has  become  quiescent  or 
healed.  With  these  facts  before  us  we  are  justified  in  believing 
that  this  difference  in  degree  of  specific  cell  sensitization 
(specific  cellular  defense)  shows  in  the  manner  in  which  the  cells 
react  to  tuberculin.  Active  tuberculosis,  being  accompanied  by 
marked  cell  sensitization,  responds  quickly  and  markedly  to 
the  tuberculin  test,  while  quiescent  or  healed  lesions  respond 
lightly  and  slowly.  This  I  have  found  clinically.  Those  pa- 
tients who  are  suffering  from  active  tuberculosis,  as  diagnosed 
by  other  methods,  respond,  as  a  rule,  to  the  skin  test,  promptly, 
reaching  the  maximum  of  their  reaction  within  the  first  twenty- 
four  to  thirty-six  hours;  while  those  in  whom  the  disease  is 
quiescent  or  partially  so,  respond  to  a  less  degree  and  more  slow- 
ly, the  maximum  reaction  being  reached  somewhat  later  if  it  ap- 
pears as  more  than  a  very  slight  reaction.  In  a  patient  with 
suspicious  clinical  history  and  a  prompt  maximum  tuberculin 
reaction,  I  would  be  inclined  to  make  a  diagnosis  of  active  tuber- 
culosis, whether  physical  examination  reveals  the  focus  or  not. 
If,  on  the  other  hand,  I  found  a  negative  reaction  under  these 
circumstances,  or  only  a  slight  reaction,  and  the  patient's  physi- 
cal condition  was  such  that  I  would  expect  a  marked  reaction  in 
the  presence  of  an  active  lesion,  I  would  be  inclined  to  feel  that 
the  patient  was  free  from  activity.  A  failure  to  react,  or  a  slight 
reaction  in  one  whose  general  condition  is  far  below  par,  would 
not  influence  my  opinion  in  the  least. 

One  difficulty  in  making  diagnoses  is  that  we  lose  sight  of  the 
fact  that  tuberculosis  is  often  concealed.  Clinical  symptoms 
of  tuberculosis  might  be  present  and,  yet,  upon  physical  exam- 
ination nothing  be  found  that  would  make  one  suspicious  of 
the  lung  being  involved.  The  lesion  might  be  in  the  mediastinal 
glands  or  any  other  glands  or  tissues  of  the  body.  I  do  not 
doubt  that  a  great  deal  of  our  distrust  and  error  in  diagnosis 
of  tuberculosis  is  due  to  this  very  fact.  We  are  always  expect- 
ing to  find  it  as  a  pulmonary  involvement,  when  it  may  be  an 
involvement  of  any  one  of  many  organs.  If  we  come  to  the 
point  of  recognizing  tuberculosis  as  such  no  matter  where  found 
(and  that  is  the  way  we  should  recognize  it;  at  least  we  should 


TUBERCULIN   TESTS  505 

recognize  active  tuberculosis  as  active  tuberculosis  whether  it  be 
in  the  bone,  or  the  joint,  or  lung,  or  wherever  found)  then  we 
would  be  making  real  genuine  progress  in  diagnosis;  but,  as  it  is 
today,  if  we  are  not  allowed  to  make  a  diagnosis  of  active  tuber- 
culosis unless  it  be  in  some  portion  of  the  body  where  it  is  going 
to  seriously  interfere  with  function,  such  as  in  the  lungs,  men- 
inges, bones,  joints,  or  peritoneum,  and  if  we  are  to  ignore  it 
when  in  the  hidden  glands,  simply  because  we  cannot  see  the 
focus,  then  we  are  going  to  continue  to  be  greatly  confused  in 
trying  to  harmonize  physical  findings,  clinical  history,  and  the 
various  reactions.  Syphilis  is  syphilis  no  matter  where  we  find 
it,  and  a  positive  Wassermann  demands  treatment.  This  is  rec- 
ognized by  all  authorities  whether  the  site  of  the  lesion  is 
found  or  not.  Why  consider  syphilis  so  dangerous  and  ignore 
tuberculosis,  or  wait  for  it  to  manifest  itself  in  some  important 
organ  before  giving  the  patient  the  benefit  of  scientific  treatment? 
The  results  of  such  a  policy  are  shown  by  the  death  rate. 

It  is  necessary  to  bear  in  mind  in  employing  tuberculin  in 
diagnosis  that  the  reactive  capacity  of  different  tissues  and  dif- 
ferent patients  as  well  as  that  of  different  tuberculins  and  different 
preparations  of  the  same  tuberculin  differs.  Sometimes  patients 
will  not  react  to  tuberculin  even  though  tuberculosis  is  present. 
Such  patients,  as  a  rule,  are  in  a  low  state  of  vitality  and  have 
built  up  no  specific  resistance  to  the  tubercle  bacillus ;  or,  if  they 
have,  it  is  in  abeyance  at  the  time.  This  is  particularly  noticed 
in  the  use  of  the  skin  test  in  persons  suffering  from  acute  infec- 
tious diseases,  such  as  diphtheria,  whooping  cough,  scarlet  fever, 
meningitis,  and  particularly  measles;  and  it  is  true  of  all  tests 
to  some  extent  in  persons  suffering  from  fever  and  cachexia  and 
those  who  are  in  a  low  state  of  vitality. 

The  subject  of  the  relationship  of  hypersensitiveness  to  the 
character  of  the  lesion,  has  been  discussed  from  the  experi- 
mental standpoint  by  A.  K.  Krause.1  In  these  experiments  he 
shows  that  the  nature  of  the  reaction  depends  upon  the  activity 
of  the  disease.  This  is  in  accord  with  the  observations  which  I 
have  made  clinically  and  discussed  previously.    I  wish  to  quote 


Experimental    Studies    on    the    Cutaneous    Reaction    to    Tuberculo-Protein,    Journal    of 
Medical  Research,  New  Series,  vol.  xxx,  September,   1916. 


506  TUBERCULIN   TESTS  IN  DIAGNOSIS 

his  general  conclusions  based  not  only  on  his  own  work  but  that  of 
Baldwin  and  Romer,  which  are  as  follows: 

1.  "There  is  no  cutaneous  hypersensitiveness  without  a  focus 
(tubercle). 

2.  "This  hypersensitiveness  appears  coincident  with  the  estab- 
lishment of  the  focus. 

3.  "It  diminishes  with  the  healing  of  the  focus. 

4.  "It  varies  directly  with  the  intensity  of  the  disease,  which 
in  its  turn  is  dependent  on  the  virulence  of  the  invading  bacil- 
lus." 

The  Subcutaneous  Test. — Koch's  Old  Tuberculin  is  employed 
in  making  the  subcutaneous  test.  While  any  tuberculin  may 
be  used,  yet  there  are  certain  reasons  why  Koch's  Old  Tuber- 
culin is  best.  The  tubercle  bacillus  is  made  up,  or  is  capable  of 
being  divided  into  many  different  substances  which  Much  has 
characterized  as  partialantigens ;  for  example,  there  are  sev- 
eral different  proteins,  also  several  different  fats  that  can  be 
derived  from  it.  The  preparations  of  tuberculin  are  made  in 
different  ways  and  contain  these  various  partialantigens  in 
different  proportions;  in  fact,  in  certain  preparations  some  of 
these  partialantigens  are  almost  wholly  wanting.  The  tissues 
of  patients  suffering  from  pulmonary  tuberculosis  contain  anti- 
bodies to  these  different  partialantigens  in  different  propor- 
tions; in  fact,  sometimes  antibodies  to  some  of  them  are  almost 
wholly  wanting;  consequently,  in  our  choice  of  a  tuberculin 
for  diagnostic  purposes  we  should  employ  one  that  contains  the 
greatest  number  of  partialantigens.  Koch's  Old  Tuberculin 
fills  this  description  best  of  all  preparations,  and  consequently  is 
the  one  we  shall  discuss.  If  several  different  forms  of  tuberculin 
are  used  at  the  same  time  in  making  the  test,  the  reactions  from 
the  different  preparations  are  not  always  uniform,  as  can  be 
readily  understood;  but  a  reaction  to  any  form  of  tuberculin  is 
proof  that  antibodies  to  the  particular  partialantigens  pres- 
ent in  the  preparation  exist  in  the  body  tissues  and  such  reac- 
tion is  of  diagnostic  importance.  It  is  further  probable  that, 
unless  the  patient  has  been  inoculated  with  that  particular 
partialantigen,  the  specific  antibodies  present  are  there,  as  a  re- 
sult of  a  tuberculous  infection. 


SUBCUTANEOUS   TEST  507 

The  dilution  of  tuberculin  for  the  test  is  simple.  Dilutions 
should  be  made  fresh  at  the  time  of  each  dose;  or  at  least  at 
intervals  not  longer  than  ten  days,  because  the  weaker  dilu- 
tions do  not  remain  active  indefinitely.  The  original  solution, 
however,  if  tightly  corked,  may  be  kept  for  a  long  time  without 
losing  its  strength. 

Dilutions  may  be  made  by  a  graduated  pipette  or  syringe. 
As  a  diluent,  normal  salt  solution,  plus  two-fifths  of  one  per 
cent  carbolic  acid  is  used.  Two  dilutions  of  the  original  tuber- 
culin should  be  made.  One  a  1 :100  is  made  by  taking  0.1  c.c. 
of  original  solution  and  diluting  it  with  9.9  c.c.  of  the  diluent. 
Of  this  solution  0.1  c.c.  equals  1  milligram  (0.001  c.c.)  of  tu- 
berculin, and  a  syringeful  or  1  c.c.  equals  10  milligrams  (0.01 
c.c.)  of  tuberculin.  To  make  the  1 :1000  dilution,  0.1  c.c.  of 
the  1 :100  dilution  should  be  taken  and  diluted  with  0.9  c.c. 
diluent.  Of  this  dilution,  0.1  c.  c.  equals,  0.1  milligram  (0.0001 
c.c)  of  tuberculin,  and  1  c.c.  equals  1  milligram  (0.001  c.c.)  of 
tuberculin.  These  two^  dilutions  are  sufficient,  because  from 
them  we  can  conveniently  measure  the  doses,  ranging  from  0.1 
mgm.  to  10  mgms.,  which  are  ordinarily  used  in  making  the  test. 

Temperature. — Preparatory  to  administering  the  subcutaneous 
test,  a  period  of  observation  of  the  patient  is  essential.  During 
this  time,  the  patient  should  live  as  carefully  as  possible,  saving 
himself  from  all  unnecessary  work  and  worry.  It  is  best  to 
have  the  patient  confined  to  bed  both  during  the  period  of  ob- 
servation and  the  time  that  the  subcutaneous  test  is  being  made ; 
but  it  is  not  essential,  and  cannot  always  be  carried  out,  especially 
in  clinic  patients.  It  is  essential,  however,  that  the  patient  live 
under  the  same  conditions  during  the  period  of  observation  and 
the  making  of  the  test.  If  he  is  in  bed  during  the  time  of  the 
test,  he  should  be  in  bed  during  the  period  of  observation.  If 
he  is  to  be  up  and  around  during  the  test,  he  should  be  the  same 
during  the  period  of  observation. 

It  is  also  essential  that  a  record  of  the  temperature  and  pulse 
be  kept  during  both  the  period  of  observation  and  during  the 
period  of  making  the  test.  This  should  be  made  accurately. 
The  temperature  should  be  recorded  at  least  four  times  a  day, 
preferably  on  awakening  in  the  morning,  at  twelve,  four  and 


508  TUBERCULIN   TESTS  IN  DIAGNOSIS 

eight  o  'clock.  The  thermometer  should  be  held  in  the  mouth  suf- 
ficiently long  to  guarantee  full  registration.  This  should  be  at 
least  five  minutes;  and  if  the  weather  is  cold  and  the  patient 
is  surrounded  by  cold  atmosphere,  it  should  be  longer  because 
it  will  often  take  ten  minutes  or  more  to  warm  the  mouth  so 
as  to  secure  full  registration.  During  the  time  that  the  patient 
is  holding  the  thermometer  he  should  not  talk,  because  opening 
and  closing  the  mouth  interferes  with  accurate  registration. 

It  is  best  to  administer  the  tuberculin  at  night  so  as  to  have 
the  opportunity  of  observing  any  rise  in  temperature  that 
would  follow  during  the  succeeding  day.  The  temperature  reac- 
tion usually  begins  sometime  between  eight  and  sixteen  hours 
after  the  injection,  so  the  rise  in  temperature  is  usually  found 
during  the  succeeding  day  if  the  test  is  given  at  night.  The  re- 
action time,  however,  varies  greatly  under  different  circumstances. 

The  subcutaneous  test  is  applicable  to  any  patient  who  is  in 
an  afebrile  condition  or  any  patient  who  is  running  a  slight  de- 
gree of  temperature.  As  a  rule,  if  the  temperature  is  above  99.6° 
or  100°,  it  is  not  applicable.  In  fact,  in  a  patient  who  is  having 
a  daily  maximum  of  99°  to  100°,  the  diagnosis,  if  due  to  tubercu- 
losis, should  usually  be  made  upon  clinical  history  and  physical 
examination  if  the  disease  is  in  the  pulmonary  tissue  or  some 
other  part  of  the  body  that  is  accessible.  If  not,  some  other  form 
of  the  test  should  be  used.  If  temperatures  above  that  mentioned 
are  due  to  tuberculosis  it  means  that  there  is  a  considerable  de- 
gree of  activity  present ;  and,  if  marked  activity  is  present,  a  tu- 
berculin reaction  such  as  that  which  is  apt  to  follow  the  injec- 
tion of  tuberculin  for  the  test,  is  best  avoided;  although  I  can 
hardly  conceive  of  a  single  tuberculin  reaction  producing  any 
serious  trouble. 

It  has  also  been  said  that  this  form  of  test  is  not  particularly 
applicable  in  hysteria  because  the  patient  may  become  excited 
and  suffer  a  rise  of  temperature  from  the  nervous  state,  which 
might  be  mistaken  for  the  reaction.  If  the  peculiar  character- 
istics of  the  tuberculin  reaction,  however,  are  remembered,  it  will 
be  seen  that  there  is  a  difference  between  the  rises  of  tempera- 
ture from  tuberculosis  and  those  due  to  other  transitory  con- 
ditions.   It  will  further  be  seen  that  any  rise  of  temperature  due 


SUBCUTANEOUS   TEST  509 

to  a  tuberculin  reaction  is  usually  accompanied  by  the  chain  of 
symptoms  which  make  up  the  general  reaction. 

In  suitable  cases  for  the  test,  that  is,  in  slight  infiltration  with- 
out much  temperature,  no  matter  where  the  lesion  is  located,  ex- 
cept in  the  meninges,  the  subcutaneous  test  is  practically  without 
danger. 

The  injection  may  be  given  in  any  portion  of  the  body.  For 
convenience,  however,  I  am  inclined  to  use  the  forearm,  upper 
arm,  or  sometimes  the  back. 

The  question  of  dosage  is  an  important  one  although  it  might 
not  seem  so  from  the  variance  in  methods  in  vogue.  There  is 
much  diversity  in  methods  of  administering  the  subcutaneous 
test.  Koch  suggested  three  doses,  1,  5,  and  10  milligrams,  the 
latter  to  be  repeated  in  case  of  failure  to  react.  These  to  be  given 
with  two  or  three  days  intervening  between  doses.  The  writer's 
method  of  giving  tuberculin  in  diagnosis  is  as  follows :  The  dos- 
age is  gauged  according  to  the  earliness  of  the  lesion,  the  tissue 
involved;  the  degree  of  activity  suspected;  and  the  physi- 
cal condition  of  the  patient.  If  the  lesion  is  early  and  inclined 
to  be  active,  smaller  doses  should  be  used  than  in  case  it  is  more 
extensive  or  the  lesion  is  fairly  quiescent.  If  the  patient  is  re- 
duced in  vitality,  smaller  doses  are  employed  than  if  the  patient 
is  stronger.  In  a  child  the  dose  is  reduced  from  one-tenth  to 
one-half  that  given  to  an  adult.  For  the  average  adult  my 
initial  dose  is  one  milligram.  Two  days  later,  if  there  is  no  re- 
action, I  give  3  or  5  milligrams;  three  days  later,  in  case  of 
no  reaction,  I  give  7  or  10  milligrams,  according  to  the  condi- 
tions. If  the  patient  is  a  child,  or  one  whose  vitality  is  lowered, 
I  would  generally  begin  with  one-tenth,  then  1,  3,  and  5  milli- 
grams. While  a  patient  might  react  to  10  who  does  not  react 
to  5,  for  the  sake  of  safety  higher  doses  are  rarely  employed. 

Nearly  all  patients  suffering  from  early  active  tuberculosis 
will  react  to  10  milligrams  if  the  proper  increase  and  spacing 
of  doses  is  followed. 

A  positive  reaction  to  a  subcutaneous  injection  of  tuberculin 
may  show  in  three  ways,  by  local,  focal,  or  general  phenomena. 
The  local  reaction  consists  in  an  irritation  at  the  point  of  injec- 
tion.   While  this,  of  itself,  is  not  generally  considered  as  a  posi- 


510  TUBERCULIN   TESTS  IN   DIAGNOSIS 

tive  reaction  in  this  form  of  the  test,  in  reality  it  is  as  much  so 
as  any  other  local  reaction. 

The  focal  reaction  is  a  reaction  in  the  tuberculous  focus  re- 
sulting from  the  combination  of  substances  found  in  or  elaborated 
from  the  tuberculin  with  the  sensitized  cells  about  the  tuber- 
culous focus;  or  as  a  result  of  specific  antibodies,  whose  forma- 
tion is  stimulated  by  the  introduction  of  tuberculin,  combining 
with  the  products  of  the  tubercle  bacillus  found  in  the  focus  of 
infection.  The  phenomena  which  appear  are  such  as  accom- 
pany any  non-specific  inflammation.  If  the  reaction  is  light,  a 
slight  hyperemia  only  occurs,  but  if  it  is  severe,  the  signs  of  a 
more  serious  congestion  with  exudation  appear,  accompanied  by 
an  increase  of  the  usual  signs  and  symptoms  which  previously 
existed. 

If  the  focal  reaction  is  in  a  pulmonary  focus  it  may  be  ac- 
companied by  a  cough  even  when  one  had  not  existed  previously ; 
or  an  increase  if  it  had  previously  existed.  An  exaggeration  of 
the  signs  on  auscultation  may  also  take  place,  and  fine  rales  may 
be  increased  or  brought  out  where  they  had  not  previously  been 
detected.  The  detection  of  a  focal  reaction  in  the  lung,  how- 
ever, is  not  an  easy  matter,  and  is  of  little  use  to  anyone  but 
an  expert  stethoscopist.  In  visible  tuberculous  ulcers,  such  as 
those  in  the  larynx,  the  focal  reaction  may  be  seen  as  an  in- 
creased hyperemia;  in  glands  it  sometimes  shows  as  an  increase 
in  the  size,  with  pain,  swelling  and  redness ;  in  the  kidney,  pain, 
increased  bacilluria,  or  hematuria  may  occur  rarely,  but  must 
not  be  expected.  In  fact,  the  focal  reaction,  while  giving  more 
positive  information,  is,  in  the  main,  misleading  and  disappoint- 
ing.   It  does  not  always  occur  following  the  doses  administered. 

A  general  reaction  is  accompanied  by  the  same  toxic  symp- 
toms as  are  noted  when  activity  is  present  in  a  tuberculous  focus, 
and  these  symptoms  differ  in  degree  the  same  as  they  do  in 
the  clinical  disease.  There  may  be  a  slight  drowsiness,  a  feeling 
of  heaviness,  a  tired  feeling,  or  an  aching,  either  slight  or  amount- 
ing to  extreme  discomfort,  such  as  accompanies  acute  infection 
(tonsillitis  or  la  grippe).  The  patient  experiences  an  increased 
nervousness,  sometimes  insomnia.  When  the  reaction  is  severe, 
a  chill  and  even  vomiting  may  precede  a  rise  of  temperature. 


SUBCUTANEOUS   TEST  511 

The  temperature  rise  was  formerly  made  the  sole  means  of  judg- 
ing the  subcutaneous  test,  and  an  elevation  of  two  degrees  was 
demanded  for  a  positive  reaction.  This  is  no  longer  necessary, 
for  those  who  have  had  experience  have  been  able  to  demon- 
strate that  the  chain  of  symptoms  previously  mentioned  almost 
always  manifest  themselves  with  a  dose  short  of  that  which 
causes  the  two  degree  rise  in  temperature.  The  lighter  symp- 
toms also  mentioned  will  sometimes  appear  without  a  rise  in  tem- 
perature, or  with  a  rise  of  only  a  fraction  of  a  degree  and  are 
just  as  specific.  The  effect  of  intercurrent  troubles  in  producing 
similar  symptoms  must  be  considered,  should  any  such  arise. 

The  diagnostic  value  of  the  general  reaction,  which  is  more 
properly  called  the  toxic  reaction,  depends  upon  the  presence 
of  specific  proteolytic  enzymes.  When  a  small  quantity  of  tuber- 
cle protein  is  injected  parenterally  into  the  body  of  a  non-tuber- 
culous subject,  no  recognizable  signs  of  reaction  follow,  because 
the  process  required  for  its  destruction  is  a  slow  one,  and  the 
toxic  molecules  are  set  free  very  slowly  and  in  such  small 
quantities  that  they  are  rendered  harmless  or  excreted  without 
producing  recognizable  effects.  When  injected  into  an  indi- 
vidual who  is  infected  with  tuberculosis,  on  the  other  hand, 
specific  proteolytic  enzymes  capable  of  splitting  it  up  into  less 
complex  molecules,  are  already  present,  and  act  upon  tuberculin 
as  soon  as  they  come  in  contact  with  it,  setting  free  the  toxic 
molecules  rapidly  and  in  large  quantities.  The  character  of  the 
reaction  depends  upon  the  rapidity  with  which  the  toxic  mole- 
cules are  liberated;  and  this,  in  turn,  depends  upon  the  amount 
and  activity  of  specific  enzymes  present.  Inasmuch  as  these  are 
present  in  greatest  amounts,  and  most  active,  when  the  body  is 
fighting  an  active  infection,  active  tuberculosis,  all  other  con- 
ditions being  equal,  reacts  to  smaller  doses  and  more  promptly 
than  quiescent  and  healed  tuberculosis.  This  gives  the  reaction 
its  diagnostic  value. 

The  general  reaction  manifests  itself  as  the  syndrome  of 
toxemia,  which  acts  through  stimulation  of  the  cells  of  the  cen- 
tral nervous  system  and  is  expressed  chiefly  as  a  general  sympa- 
thetic stimulation.  The  cause  of  the  fever,  as  described  in 
Volume  II,  Chapter  XXX,  is  not  so  much  the  increase  in  heat  pro- 


512 


TUBERCULIN  TESTS  IN  DIAGNOSIS 


duction  as  it  is  a  stimulation  of  the  vasoconstrictors  which  in- 
terfere with  the  elimination  of  heat  from  the  surface  of  the  body. 
The  temperature  following  tuberculin  has  certain  peculiarities 
which  are  almost  diagnostic  of  themselves.  If  Koch's  Old  Tuber- 
culin is  employed,  and  it  is  best,  the  temperature  usually  comes 
on  sometime  between  eight  and  twenty-four  hours  after  the 
injection.  The  temperature  usually  rises  gradually.  It  may  take 
twenty-four  hours  to  reach  its  maximum  and  then  it  falls  gradu- 
ally. I  have  never  seen  a  reaction  of  more  than  a  small  fraction 
of  a  degree,  which  was  positively  due  to  tuberculin,  in  which 
the  maximum  temperature  was  followed  in  a  few  hours  by  a 
normal.  The  morning  temperature  on  the  day  following  a  posi- 
tive tuberculin  reaction  is  nearly  always  above  the  usual  morning 


Fig.  98. — Three  different  temperature  curves,  illustrating  tuberculin  reactions.  It  will 
be  noted  that  the  temperature  does  not  return  to  normal  on  the  second  day  of  the 
reaction.     This  is  characteristic   of  the  curve  of  the  tuberculin   reactions. 


register.    The  accompanying  curve,  from  the  author's  monograph 
on  tuberculin,2  illustrates  this  point  (Fig.  98). 

The  Cutaneous  Tuberculin  Test  (von  Pirquet). — The  cutaneous 
tuberculin  test,  which  is  commonly  called  the  von  Pirquet  test, 
was  brought  forth  by  von  Pirquet  in  1907.  He  explains  it  as 
being  a  reaction  of  hypersensibility  and  due  to  a  condition  which 
he  has  described  as  allergy,  from  ergeia,  meaning  reactivity  and 
alios,  meaning  altered.  He  means  by  this  that  in  tuberculous 
patients  the  reactivity  of  the  cells  is  altered  from  what  it  is  in 
those  who  are  non-tuberculous,  and  that  this  alteration  mani- 


2Tuberculin  in  Diagnosis  and  Treatment,  C.  V.  Mosby  Co.,  1913. 


CUTANEOUS   TEST  513 

fests  itself  in  a  specific  method  of  reacting  when  tubercle  bacilli 
or  the  products  of  tubercle  bacilli  are  brought  in  contact  with 
them. 

The  cutaneous,  like  the  subcutaneous  test,  depends  for  its 
diagnostic  value  upon  the  fact  that  the  infected  individual  pos- 
sesses within  his  body  specific  proteolytic  enzymes  which  rapidly 
split  the  protein  molecule  contained  in  the  tuberculin  into  simpler 
molecules.  While  the  subcutaneous  reaction  depends  on  the  toxic 
molecule,  the  cutaneoius,  along  with  the  percutaneous,  intra- 
dermal and  conjunctival,  depends  upon  the  sensitizing  molecule 
for  its  reactive  phenomena. 

This  reaction  is  more  specific  than  the  toxic  reaction;  in  fact, 
the  factor  which  makes  the  toxic  reaction  (subcutaneous)  of  any 
value  at  all  in  diagnosis,  is  the  rapidity  of  the  destruction  of  the 
tubercle  protein,  resulting  in  prompt  liberation  of  the  toxic 
molecule. 

The  real  diagnostic  worth  of  the  cutaneous  test  is  not  in  the 
mere  presence  or  absence  of  a  reaction.  Some  evidence  of  sensi- 
tization should  be  expected  in  all  patients  who  have  harbored  in- 
fection within  their  bodies.  Clinical  experience,  however,  seems 
to  show  that  this  gradually  lessens  until  it  may  finally  disappear 
after  the  infection  has  been  healed  for  a  term  of  years.  The  na- 
ture of  the  reaction,  however,  affords  valuable  diagnostic  evi- 
dence. It  gives  an  idea  of  the  degree  of  sensitization  present. 
If  marked  sensitization  is  present  it  suggests  that  the  patient  is, 
or  has  been  recently,  fighting  active  tuberculosis.  Otherwise 
there  would  be  no  need  for  the  presence  of  the  large  amounts  of 
specific  enzymes  which  are  responsible  for  the  reaction. 

I  have  gradually  learned  to  suspect  that  the  patient  who  re- 
acts promptly  with  a  marked  reaction  reaching  the  maximum 
within  the  first  twenty-four  or  thirty-six  hours,  does  so  because 
the  body  is  well  supplied  with  specific  enzymes  as  a  result  of 
an  unhealed  focus.  The  degree  of  promptness  of  the  reaction 
in  this  test,  the  same  as  in  the  preceding,  depends  upon  the 
rapidity  with  which  the  tubercle  protein  is  split,  consequently, 
upon  the  number  of  specific  enzymes,  which  are  governed  by  the 
urgency  of  defense. 

Before  making  the  cutaneous  test,  the  skin  should  be  cleansed 


514  TUBERCULIN   TESTS  IN  DIAGNOSIS 

with  alcohol  or  ether  and  allowed  to  dry.  The  test  is  then  made 
by  placing  a  drop  of  the  solution  of  tuberculin  to  be  used,  on  the 
skin  and  producing  an  abrasion  of  the  skin  through  the  drop. 
This  method  is  much  better  than  to  make  the  abrasion  first  and 
put  on  the  tuberculin  afterwards;  because,  by  this  method  of 
making  the  abrasion,  the  tuberculin  is  mechanically  pressed  into 
the  tissues  and  thus  comes  in  surer  contact  with  them.  The 
scarifier  devised  by  von  Pirquet  is  much  better  than  the  scalpel 
because  it  is  desirable  not  only  to  determine  whether  or  not  a 
reaction  is  present,  but  the  degree  of  the  reaction.  This  cannot 
be  so  accurately  done  when  there  has  been  considerable  trauma, 
as  often  occurs  when  the  scalpel  is  used.  It  is  well  to  make  a 
control  abrasion  without  tuberculin,  for  the  purpose  of  com- 
paring the  traumatic  reaction  with  the  tuberculin  reaction  if 
present.  In  making  this  test,  I,  personally,  prefer  to  use  100 
per  cent  strength  of  tuberculin,  although  25  per  cent  and  50 
per  cent  may  be  used,  if  desired.  I  have  never  seen  any  harm 
from  the  100  per  cent  and  have  found  some  positive  reactions 
with  the  full  strength  which  were  more  or  less  doubtful  with 
weaker  dilutions.  Tests  may  be  made  anywhere  on  the  body; 
but,  for  convenience,  I  prefer  the  forearm,  although  there  are 
some  reasons  in  favor  of  choosing  a  portion  of  the  skin  which  is 
more  delicate,  such  as  that  over  the  thorax.  Sometimes  the  deli- 
cate skin  will  give  a  more  marked  reaction  than  the  skin  of 
those  parts  which  are  less  sensitive. 

This  test  should  be  given  in  a  definite  manner.  Its  very  sim- 
plicity often  leads  to  a  haphazard  method  of  making  it  and  this 
militates  against  its  usefulness.  The  tuberculin  should  be  brought 
into  close  contact  with  the  subcutaneous  tissue  and  should  be  al- 
lowed to  remain  in  contact  for  a  sufficient  time  for  absorption  to 
take  place.  Five  minutes  is  usually  sufficient.  The  patient  should 
then  be  instructed  not  to  allow  the  clothing  to  wipe  it  off.  Some 
clinicians  cover  the  abrasion  with  a  gauze  protection,  but  this 
is  not  necessary.  Not  only  the  reaction,  but  the  strength  of  the 
reaction,  and  the  time  of  its  appearance  should  be  noted. 

A  positive  reaction  consists  in  an  area  of  redness  appearing 
at  the  seat  of  the  inoculation.  Sometimes  it  is  only  a  slight  red- 
ness of  the  tissue  surrounding  the  trauma,  which  can  hardly  be 


.2B 


.2  A 


SA. 


3B. 


Platb  VI. 

1.  Conjunctival  reaction  of  left  eye. 

2/4.  Von   Pirquet   reaction,   well   marked;    B,   control   site 

3A.  Von  Pirquet  reaction,  moderate;   B,   control  site. 

4.  Moro    reaction,   well   marked. 

5.  Moro  reaction,  slight. 


PERCUTANEOUS   AND    CONJUNCTIVAL   TESTS  515 

differentiated  from  the  traumatic  reaction  of  the  tissues.  Some- 
times it  consists  of  a  papule  which  may  even  form  a  vesicle. 
Surrounding  the  papule  there  is  usually  an  area  of  redness  of 
varying  extent,  and  at  times  the  reaction  can  be  traced  out  along 
the  lymph  channels  for  a  distance  of  several  centimeters.  A  very 
marked  reaction  may  be  four  or  five  centimeters  in  diameter.  It 
is  possible  that  sufficient  tuberculin  may  be  absorbed  to  cause  a 
temperature  reaction  in  very  sensitive  individuals.  Such  in- 
stances have  been  reported  but  the  writer  has  never  seen  it  occur. 
Plate  VI  (3  a  and  b)  illustrates  the  cutaneous  reaction. 

The  Percutaneous  Test  (Moro). — The  percutaneous  test  is  made 
by  rubbing  a  mixture  of  equal  parts  of  Koch's  Old  Tuberculin 
and  lanolin  into  the  uninjured  skin.  Of  this  an  amount  equal 
to  the  size  of  a  pea  is  used.  It  is  best  to  use  some  portion  of 
the  skin  that  is  protected  and  sensitive.  This  test  is  not  as  reli- 
able as  the  cutaneous  because  of  more  or  less  error  in  securing 
absorption.  The  reaction  usually  occurs  in  twenty-four  to  forty- 
eight  hours  after  the  inoculation  and  shows  as  a  number  of  small 
red  spots,  but  if  the  reaction  is  severe  they  may  take  the  form 
of  small  nodules  lasting  for  several  days.    (See  Plate  VI,  4  and  5.) 

The  Conjunctival  Test  (Wolff -Eisner). — The  conjunctival  test 
which  was  brought  out  by  Wolff-Eisner  and  later  by  Calmette 
is  gradually  falling  into  disuse,  owing  to  the  more  simple  cu- 
taneous and  percutaneous  methods. 

Koch's  Old  Tuberculin  is  used  for  the  test.  Two  dilutions  are 
made,  a  one  and  a  two  per  cent  strength.  One  or  two  drops  of 
the  one  per  cent  is  instilled  into  one  eye.  If  no  reaction  occurs, 
later  a  two  per  cent  should  be  instilled  into  the  other  eye.  A 
positive  reaction  is  shown  by  the  development  of  hyperemia.  If 
the  reaction  is  slight  there  is  only  a  faint  redness  of  the  con- 
junctiva, but  there  may  be  a  marked  conjunctivitis,  even  puru- 
lent in  character,  if  the  reaction  is  severe.  It  should  be  used  in 
any  case  where  the  eye  is  diseased,  particularly  if  the  disease  is 
of  a  tuberculous  nature.     This  reaction  is  shown  in  Plate  VI,  1. 

The  Intradermal  Test  is  made  by  injecting  a  few  drops  of  a 
dilution  of  1-1000  or  1-5000  of  Koch's  Old  Tuberculin  between  the 
layers  of  the  skin.     A  positive  reaction  shows  as  an  induration. 


CHAPTER  XIX. 

THE  X-RAY  AS  AN  AID  TO  THE  DIAGNOSIS  OF 
PULMONARY  TUBERCULOSIS. 

Relative  Value  of  Physical  and  X-Ray  Examinations. — The 

difficulty  as  well  as  the  importance  of  early  diagnosis  of  tuber- 
culosis reveals  itself  in  the  great  number  of  methods  which  have 
been  suggested  to  detect  this  disease  during  the  period  when  the 
pathological  changes  are  slight.  The  most  important  methods 
for  the  diagnosis  of  early  clinical  tuberculosis  are  the  clinical 
history  and  physical  examination  of  the  patient.  These  two 
alone,  if  the  history  is  taken  with  sufficient  care  and  the  ex- 
amination is  made  with  sufficient  skill,  will  determine  the  pres- 
ence or  absence  of  tuberculosis  in  nearly  all  instances. 

As  supplementary  aids  to  these  important  measures,  however, 
we  have  the  examination  of  the  sputum  for  bacilli,  lymphocytes, 
and  albumin;  the  complement  deviation  and  opsonic  tests;  the 
tuberculin  tests;  and  the  x-ray.  Each  of  these  methods  of  ex- 
amination may  become  an  important  aid  under  certain  circum- 
stances. This  is  particularly  true  of  the  examination  for  bacilli, 
the  tuberculin  tests  and  the  x-ray.  These  supplementary  tests, 
however,  should  be  considered  only  as  aids  to  diagnosis  and 
should  be  used  in  conjunction  with  the  clinical  history  and  the 
physical  examination. 

When  the  x-ray  was  first  discovered  it  was  hoped  that  a 
method  had  come  into  vogue  which  would  give  an  accurate 
picture  of  all  conditions  within  the  thorax,  but  it  was  soon 
learned  that  such  was  not  the  case. 

It  has  taken  a  number  of  years  to  determine  the  relative 
value  of  the  x-ray  examination  as  compared  with  the  clinical 
examination.  Clinicians  who  have  had  most  experience  and 
are  best  able  to  judge  are  in  accord  in  their  opinion  that  an  ac- 
curate clinical  history  and  a  skillful  physical  examination  will 
reveal  changes  which  result  from  tuberculosis  earlier  than  can 


RELATIVE   VALUE    OF   X-RAY   EXAMINATION  517 

be  shown  by  the  x-ray  examination.  From  the  practical  stand- 
point, however,  this  is  not  the  question  of  greatest  importance. 
The  question  is :  how  may  the  x-ray  be  used  to  give  the  greatest 
aid  in  the  diagnosis  of  early  tuberculosis?  "While  the  value  of  a 
skillful  clinical  examination  cannot  be  questioned,  yet  it  is  but 
fair  to  admit  that  proper  accuracy  and  skill  are  not  always  ap- 
plied. 

Cases  of  early  tuberculosis  will  be  found  among  every  man's 
patients ;  and  every  man  who  does  any  considerable  practice  will 
at  times  suspect  tuberculosis.  Many  will  overlook  the  disease 
because  of  their  inability  to  make  the  clinical  examination  with 
sufficient  skill.  Diagnosis  at  such  times  will  be  facilitated 
either  by  a  skillful  clinical  consultant  or  by  having  the  aid  of 
an  expert  radiographer.  Even  the  men  who  make  the  most  care- 
ful examinations  find  themselves  puzzled  now  and  then,  and  can 
be  aided  greatly  by  the  study  of  an  x-ray  picture,  particularly 
the  stereoscopic  picture  made  by  one  skilled  in  pulmonary  ront- 
genology. It  is  important  in  this  connection,  to  have  in  mind 
that  the  plate  and  screen  are,  at  least  equally  and  probably 
more  likely  to  present  inaccuracies  than  the  careful  physical 
examination.  It  must  not  be  taken  as  an  infallible  picture,  nor 
must  its  interpretation  be  taken  as  being  without  error. 

The  practical  question  which  confronts  us  in  this  discussion  is : 
can  a  more  general  use  of  the  x-ray  result  in  causing  diagnoses 
of  pulmonary  tuberculosis  to  be  made  earlier  than  they  are  being 
made  by  present  clinical  methods?  The  answer  to  this  question 
cannot  be  given  except  by  considering  the  relative  skill  of  the 
examiners.  It  seems  to  me  that  whenever  the  skill  of  the  ex- 
aminers is  at  all  nearly  equal,  preference  should  be  given  to  the 
personal  clinical  examination  rather  than  to  the  impersonal  x-ray 
plate.  The  human  side  of  medicine  must  not  be  underestimated. 
The  analysis  of  the  case,  the  symptoms,  the  clinical  course,  and 
the  data  found  on  physical  examination  as  belonging  to  and 
being  a  part  of  a  process  within  a  human  being  is  all  important. 
In  other  words,  the  ultimate  diagnosis  should  be  made  by  the  cli- 
nician. However,  the  employment  of  an  expert  x-ray  operator, 
the  same  as  an  expert  clinical  consultant  by  men  who  are  not 
able,  or  at  least  by  those  who  do  not  make  careful  chest  examina- 


518  X-RAY   AS   AID   TO   DIAGNOSIS 

tions,  would  undoubtedly  reduce  the  percentage  of  error  in 
diagnosis  very  materially.  On  the  other  hand,  reliance  placed 
on  poor  plates  made  by  unskilled  workers  can  only  mislead.  Such 
x-ray  examinations  are  on  a  par  with  poor  physical  examina- 
tions, and  cannot  be  relied  upon. 

There  has  been  considerable  discussion  as  to  whether  or  not 
active  tuberculosis  can  be  differentiated  from  healed  tuberculosis 
by  the  x-ray  picture,  particularly  when  the  lesion  is  young. 
Skilled  operators  who  use  up-to-date  technic  and  who  have 
most  experience  in  chest  work  claim  it  possible  to  do  so.  Such 
diagnoses,  however,  should  not  be  accepted  without  careful  com- 
parison with  the  data  found  upon  clinical  examination.  The 
earliest  pathological  changes  in  tuberculosis  of  the  lung  are  not 
gross.  There  is  no  calcined  tubercle,  neither  is  there  fibrous 
tissue.  There  are  fresh  tubercles  surrounded  by  areas  of  exuda- 
tive inflammation  of  a  mild  degree.  This  condition  is  rarely 
diagnosed  except  by  expert  clinicians,  and  it  is  decidedly  ques- 
tionable whether  a  shadow  would  be  shown  on  the  screen  as  a  re- 
sult of  it.  The  fluoroscope  should  show  the  altered  motion  of  the 
diaphragm;  and  this,  together  with  the  changes  in  the  tone 
(spasm)  of  the  apical  muscles  should  direct  the  examiner  to  the 
pulmonary  involvement. 

Minor1  says:  "After  having  used  the  rontgen  ray  fluoroscopic- 
ally  in  all  his  examinations  for  the  past  seven  years,  the  writer 
believes  that  in  the  majority  of  cases  an  expert  physical  diagnos- 
tician will  be  able  to  make  a  diagnosis  of  incipient  tuberculosis 
sooner  than  will  the  radiologist;  but,  in  a  few  cases,  the  latter 
will  discover  small  foci  of  tubercle  in  the  lung  which  neither 
auscultation  nor  percussion  would  reveal.  There  are  certain 
pulmonary  conditions,  especially  enlargements  of  the  tracheo- 
bronchial glands  and  peribronchial  infiltrations  which  can  be 
diagnosed  far  earlier  and  better  by  this  method  than  by  any 
other. ' ' 

Gregory  Cole2  states  that  the  x-ray  plate,  when  properly  in- 
terpreted, will  make  the  diagnosis  of  early  pulmonary  tubercu- 


^lebs:     Tuberculosis,  D.  Appleton  &  Co.,  1909. 

2The  Radiographic  Diagnosis  and  Classification  of  Early  Pulmonary  Tuberculosis,  Amer- 
ican Journal  of  Medical  Sciences,  July,  1910. 


RELATIVE    VALUE    OF   X-RAY   EXAMINATIONS  519 

losis  earlier  than  either  the  fluoroscope  or  physical  examinations. 

Vincent  Y.  Bowditch3  says:  "In  spite  of  the  great  advance 
that  has  been  made  in  the  practical  use  of  the  x-ray  of  late  years, 
I  can  but  feel  that  we  have  not  yet  sufficiently  studied  the  causes 
of  the  phenomena  shown  by  this  method  to  warrant  our  drawing 
what  have  seemed  to  me  at  times  hasty  conclusions  as  to  the 
amount  and  nature  of  disease  which  may  be  present  in  the  lung. 
One  thing  is  absolutely  certain  in  my  mind,  viz. :  that  I  have 
very  little  faith  in  the  findings  of  anyone  but  those  who  are 
experts  in  this  department  of  science,  but  I  must  unhesitatingly 
condemn  the  diagnosis  of  those  who,  upon  the  insufficient  ground 
of  their  own  supposed  findings  in  the  use  of  the  x-ray,  give 
their  patients  unnecessary  alarm  and  anxiety  as  to  their  bodily 
condition." 

Bonney4  made  a  careful  comparison  of  physical  examinations 
and  radiography  and  states:  "As  a  result  of  this  inquiry,  how- 
ever, previous  convictions  as  to  the  slight  practical  value  of  the 
x-ray  in  the  diagnosis  of  very  incipient  cases  without  well  de- 
fined structural  lesions  have  been  substantially  confirmed." 

Heise  and  Sampson,5  after  an  analysis  of  their  own  experience 
in  ninety-five  very  early  and  difficult  cases,  take  a  very  com- 
mendable stand  on  the  comparative  advantage  of  physical  ex- 
amination and  the  x-ray,  as  follows: 

"1.  When  the  history  and  physical  examination  were  posi- 
tive, the  x-ray  showed  a  lesion  in  77  per  cent  and  failed  to  show 
a  lesion  in  23  per  cent. 

"2.  When  the  history  and  physical  examination  were  nega- 
tive, the  x-ray  failed  to  show  a  lesion  in  58  per  cent  and  dis- 
closed one  in  42  per  cent. 

"3.  When  the  history  was  positive  and  the  physical  examina- 
tion negative,  the  x-ray  showed  a  lesion  in  60  per  cent  and  failed 
to  show  one  in  40  per  cent. 

"4.  When  the  history  was  negative  but  the  physical  examina- 
tion was  positive,  the  x-ray  showed  a  lesion  in  50  per  cent 
and  failed  to  show  one  in  50  per  cent. 


3What  the  General  Practitioner  Should  Know  About  Incipient  Pulmonary  Tuberculosis, 
Boston  Medical   and   Surgical  Journal,   November  25,   1915. 

^Pulmonary  Tuberculosis  and  Its  Complications,  W.  B.  Saunders  Co.,  1908. 

"The  X-Ray  in  the  Diagnosis  of  Pulmonary  Tuberculosis,  Interstate  Medical  Journal, 
vol.  xxii,  No.   10,   1915. 


520  X-RAY  AS  AID   TO  DIAGNOSIS 

"At  first  thought  these  results  may  seem  to  indicate  that  the 
x-ray  has  but  little  value  as  an  aid  in  diagnosis.  But  when  we 
consider  that  the  basis  of  classification  and  the  class  of  cases 
in  which  the  comparison  was  used,  the  advantage  that  the  x-ray 
affords  is  really  obvious.  In  only  23  per  cent  of  all  were  the 
history  and  physical  examination  both  positive.  In  35  per  cent 
of  the  cases  both  history  and  physical  examination  were  doubt- 
ful or  negative.  The  history  only  was  positive  in  32  per  cent 
and  the  physical  examination  alone  was  positive  in  10  per  cent. 
As  the  disease  is  more  advanced  naturally  the  percentage  of 
definite  lesions  seen  in  the  plate  becomes  proportionately  greater. 
And  it  is  a  fairly  common  experience  to  find  more  extensive  in- 
volvement upon  x-ray  examination  than  is  detected  by  physical 
signs.     At  times  the  difference  is  so  great  as  to  be  astounding. 

"Plates  taken  at  intervals  in  the  course  of  the  disease  will 
show  marked  changes  in  some  instances  and  at  times  these 
changes  are  detected  before  physical  signs  have  perceptibly  al- 
tered. 

"In  the  differential  diagnosis  of  mediastinal  and  lung  condi- 
tions the  value  of  the  x-ray  is  unquestionable,  but  this  phase  of 
the  subject  will  not  be  dealt  with  here. 

"In  conclusion,  we  would  like  to  state  that  in  our  opinion 
the  x-ray  in  diagnosis  can  be  made  to  give,  as  nearly  as  pos- 
sible without  exploration  or  autopsy,  evidences  of  the  existing 
pathology  in  the  lungs.  It  has  been  of  distinct  advantage  in 
the  diagnosis  and  better  understanding  of  existing  lesions  in  the 
lung,  and  with  plates  taken  at  intervals,  changes  for  better  or 
worse  have  been  noted  in  the  areas  involved.  Owing,  however, 
to  the  fact  that  the  x-ray  is  a  shadow  projector  only,  we  do 
not  think  it  infallible  and  that  it  should  at  the  present  time,  at 
least,  replace  all  other  methods  of  diagnosis.  Bather  do  we 
think  it  should  be  used  in  cooperation  with  all  methods — as  an 
aid  rather  than  an  infallible  means." 

In  using  the  x-ray  it  must  be  remembered  that  slight  lesions 
produced  by  early  tuberculosis  may  not  produce  sufficient 
changes  in  the  density  of  the  tissues  to  alter  the  shadow,  and 
yet  may  be  detected  by  expert  physical  examination. 

There  are  several  portions  of  the  lung  which  should  be  exam- 


INTERPRETATION    OF   PLATE  521 

ined  especially  carefully  for  tuberculosis,  although  foci  may  ap- 
pear in  any  part.  Thanks  to  the  x-ray  we  have  learned  of  the 
frequency  of  hilus  infection.  We  have  found  it  necessary  to 
change  our  ideas  of  physical  diagnosis  and  search  for  early  tuber- 
culosis in  wider  areas  than  formerly.  While  the  apex  still  holds 
its  place  as  the  common  seat  of  early  clinical  tuberculosis,  yet 
we  commonly  find  infections  near  the  hilus,  running  out  into  the 
tissue  in  all  directions,  but  particularly  toward  the  apex  and  the 
base.  These  hilus  infections  are  especially  difficult  of  detection 
on  percussion  and  auscultation  and  here  the  x-ray  has  given 
great  aid. 

Interpretation  of  Plate. — It  requires  experience  to  read  and  in- 
terpret x-ray  plates.  While  there  is  room  for  much  error  in 
making  the  plate,  one  must  not  lose  sight  of  the  fact  that  the 
greatest  skill  and  judgment  is  required  to  interpret  the  plate. 

We  should  expect  the  dense  fibrous  tissue  of  the  healed  tuber- 
cle and  the  calcified  tubercle  to  interfere  most  with  the  penetra- 
tion of  the  rays,  consequently  we  would  expect  the  shadows  cast 
by  such  structures  to  be  more  definite  and  clear  cut  than  those 
produced  by  tissue  of  lesser  density.  On  the  other  hand,  we 
would  expect  active  tubercles,  which  are  surrounded  by  an 
exudative  inflammation,  whether  isolated  or  conglomerate,  to 
produce  a  hazy  undefined  shadow,  and  the  latter  particularly  to 
show  a  mottling  of  the  plate. 

The  shadows  cast  depend  on  a  great  many  things  such  as  the 
character  of  the  tube,  the  exposure,  the  depth  of  the  lesion,  and 
the  chemical  constituents  of  the  focus.  Assmann6  made  a 
careful  study  and  comparison  of  x-ray  findings  and  postmortem 
findings.  He  says:  "At  times  the  x-ray  shows  details  of  un- 
expected minuteness;  for  example,  nodules  scarcely  as  large  as 
pin  heads  are  at  times  shown,  exact  in  position,  size  and  rela- 
tionship. Again,  nodules  as  large  as  walnuts  fail  to  appear  on 
the  plate  and  areas  of  thickened  tissue  even  larger  than  this,  cast 
no  shadows  or  shadows  which  are  scarcely  recognizable.  Aside 
from  the  thickness  and  specific  chemical  composition  of  the  focus, 
the  detail  of  the  shadow  which  it  produces  depends  upon  its  depth 
in  the  tissues." 


6Erfahrungen  iiber  die  Rontgenuntersuchnug  der  I<ungen,  Jena,  1914. 


522  X-RAY  AS  AID   TO  DIAGNOSIS 

Normal  Hilus  and  Trunk  Shadows. — The  normal  hilus  shadow 
and  the  normal  trunks  running  out  from  the  hilus  must  be  un- 
derstood in  order  to  correctly  interpret  the  abnormal.  Unfor- 
tunately, the  interpretation  of  these  shadows  is  accompanied  by 
great  uncertainty.  These  shadows  differ  with  age,  being  slight- 
er in  children  and  becoming  more  pronounced  as  the  individual 
grows  older.  As  Dunham7  well  says:  "Thus,  in  children  under 
twelve  .  .  .  the  trunks  and  marking  can  only  be  made  out  on 
plates  which  are  taken  very  rapidly,  and  in  subjects  over  sixty 
the  changes  are  so  marked  that  they  would  indicate  tuberculosis 
in  a  youth  of  eighteen. ' ' 

There  has  been  a  great  deal  of  speculation  as  to  the  cause 
of  the  trunk  shadows  in  the  x-ray  plate  of  the  normal  lung.  If 
this  could  be  definitely  determined  it  would  simplify  the  read- 
ing of  the  plate  in  pathological  lungs.  Some  (De  la  Camp,  Arns- 
perger)  believe  it  is  the  bronchi;  others  (Albers  Schonberg,  Holz- 
knecht)  the  blood  vessels;  while  still  others  think  it  is  a  combina- 
tion of  the  bronchi  and  blood  vessels. 

Assmann  has  thrown  light  on  this  point  experimentally.  He 
tied  the  vessels  of  one  lung  of  a  dog  before  killing,  leaving  the 
vessels  of  the  other  free.  He  then  removed  the  lungs,  washed  the 
blood  from  the  free  side,  inflated  the  lungs,  and  made  plates  for 
study.  The  resulting  picture  showed  "thick  solid  branched 
trunk  shadows  on  the  side  filled  with  blood,  which  were  absent 
on  the  other  side. ' '  In  discussing  the  experiment  he  says : ' '  There- 
fore it  is  made  clear  that  the  elastic  vessels  filled  with  blood 
cause  intensive  shadow  markings  in  the  form  of  well  defined 
branched  trunks."  The  author  brings  forth  further  evidence  on 
this  point  in  pointing  out  that  the  hyperemic  lung  shows  enor- 
mously large  trunk  shadows  in  comparison  with  the  normal 
lung.  He  further  quotes  Weber  and  Owen  who  filled  the 
bronchi  with  shot  so  loosely  that  the  individual  shot  were  sepa- 
rated from  each  other.  The  shadow  of  the  shot  was  found  in  a 
clear  background  instead  of  in  the  shadow  trunks  of  the  plate. 

Since  all  structures  which  interfere  with  the  passage  of  the 
rays,  increase  the  shadows  relatively  on  the  plate,  it  seems  to 


'Stereoroentgenography,   Pulmonary  Tuberculosis,  The  Southworth   Co.,  1915. 


CAUSE   OF   SHADOW   MASKINGS  523 

me  that  we  must  assume  that  blood  vessels,  lymphatics,  and 
bronchi  all  have  a  part  in  causing  the  shadow  markings  of  the 
normal  lung;  and  that  thickening  of  the  walls  of  the  bronchi 
and  lymphatic  trunks,  or  dilatation  of  the  blood  vessels  would 
cause  increase  in  the  shadow  and  should  be  considered  as  patho- 
logical. This  increase  in  trunk  markings  is  to  be  separated  from 
the  shadows  cast  by  the  pathological  changes  in  the  pulmonary 
tissue  itself. 

In  considering  the  effect  of  the  blood  vessels  in  the  produc- 
tion of  the  shadows,  we  must  bear  in  mind  that  the  contrast 
between  the  solid  blood  column  and  the  light  air  containing  lung 
tissue  is  exceedingly  great. 

Stiirtz8  suggested  that  the  markings  in  incipient  tuberculosis 
extended  from  the  hilus  to  the  apex  and  that  the  apex  was  in- 
fected through  direct  lymphatic  extension.  Such  a  condition 
seems  extremely  unlikely  upon  pathological  grounds.  While 
bacilli  may  make  headway  against  the  lymph  stream  (Tendeloo) 
yet  it  is  difficult  to  believe  that  they  could  bridge  the  gap  be- 
tween the  hilus  and  the  periphery  of  the  lung  without  the  in- 
tervening tissue  becoming  invaded. 

Dunham9  has  described  these  same  markings  extending  from 
the  hilus  to  the  periphery;  but  insists  on  certain  special  charac- 
teristics as  being  indicative  of  tuberculosis.  His  studies  were 
made  with  the  stereoscopic  plate.  To  quote  from  his  own  writ- 
ings:10 "The  anatomical  explanation  of  this  altered  shadow  pic- 
ture, I  am  not  at  this  time  ready  to  discuss,  though  I  believe  it 
is  due  to  connective  tissue  changes.  I  am  sure,  however,  that 
the  increase  in  the  hilus  shadow,  the  thickening  of  the  trunks, 
together  with  such  alterations  in  the  linear  markings  as  increase 
in  density  and  breadth,  studding,  interweaving  and  extension  to 
the  periphery,  constitute  a  shadow  picture  characteristic  of 
early  pulmonary  tuberculosis. 

"As  the  lesion  progresses  the  alterations  become  more  marked, 
the  linear  markings  more  broken  up  and  irregular,  the  studdings 
become  larger  and  denser,  the  interweavings  closer  until  eventu- 


sDie  lymphangitische  Entstellung  des  L,ungenspitzencatarrhs  von  den  Hilusdriisen  aus 
4  Versammlung  d.  Tuberkulose-Arzte,  Berlin,  1907. 

9Johns  Hopkins  Hospital  Bulletin,  vol.  xxii,  No.  245,  July,  1911;  also  Stereoroentgen- 
ology,  The  Southworth  Co.,   1915. 

10Stereorcentgenology,   The  Southworth   Co.,   1915. 


524  X-RAY  AS  AID   TO  DIAGNOSIS 

ally  all  the  markings  are  blotted  out  and  the  whole  area  appears 
as  a  unified  mass  of  increased  density,  due  to  the  presence  of 
gross  areas  of  consolidation  within  the  lung." 

Until  the  cause  of  these  changes  in  the  linear  markings  is  defi- 
nitely settled  we  can  only  speculate  as  to  the  manner  of  their 
production.  It  seems  to  me,  however,  that  the  key  to  the  explana- 
tion lies  in:  (1),  The  cause  of  the  linear  markings;  and  (2),  the 
fact  that  drainage  is  toward  the  hilus. 

If  the  normal  trunk  shadows,  both  large  and  small,  are  due 
to  a  combination  of  blood  vessels,  bronchi  and  lymphatics,  let 
us  inquire  into  what  there  is  in  early  tuberculosis  which  could 
enlarge  these  and  make  them  cast  a  broader  and  denser  shadow. 

We  could  not  expect  thickening  of  the  larger  bronchi  to  take 
place  this  early.  We  might  expect  a  certain  amount  of  obstruc- 
tion in  the  circulation  to  be  caused  by  the  infiltration,  for  there 
is  some  hyperemia  associated  with  these  early  infiltrations,  al- 
though the  amount  is  much  less  than  that  which  occurs  later  in 
the  disease.  It  is  also  not  at  all  improbable  that  as  the  products 
of  inflammation  are  carried  through  the  lymphatics  away  from 
the  diseased  areas  toward  the  hilus  they  irritate  and  produce 
changes  in  the  tissues  through  which  they  pass,  which  might 
cause  slight  alterations  in  the  shadow.  These  two  factors  seem 
to  me  to  be  worthy  of  consideration  in  accounting  for  changes 
in  the  shadow  markings.  The  distension  of  the  blood  vessels  is 
especially  important  in  connection  with  the  studies  of  Assmann 
quoted  above. 

Methods  of  Using  the  X-Ray  in  Pulmonary  Diagnosis. — The 
x-ray  may  be  employed  in  three  different  ways  in  the  examina- 
tion of  the  chest:  First,  in  making  the  single  plate;  second,  the 
stereoscopic  plate;  and  third,  in  making  a  fluoroscopic  examina- 
tion, it^flf  f 

Each  method  has  merit.  Wherever  stereoscopic  plates  can  be 
had  they  have  a  great  advantage  over  the  single  plate  in  that  the 
different  structures  stand  out  in  their  true  relationship.  Plates 
are  valuable  as  permanent  records  of  conditions.  The  fluoro- 
scope,  however,  is  more  flexible,  but  fails  in  definition.  It  per- 
mits of  studying  the  chest  from  different  angles.  It  also  offers 
an  advantage  in  studying  the  motility  of  the  chest  wall  and  par- 


METHODS   OF  USING  X-RAY  525 

ticularly  the  diaphragm.  The  interference  with  the  action  of  the 
diaphragm  in  early  tuberculosis,  as  pointed  out  by  Williams  in 
1907,  is  probably  due  to  two  factors:  the  reflex  disturbance  in 
motility  produced  through  the  phrenics  by  irritation  of  the 
nerve  cells  in  the  third,  fourth,  and  fifth  cervical  segments  of  the 
cord  by  afferent  impulses  which  travel  through  the  sympathetics 
and  rami  communicantes  from  the  inflammation  in  the  lung  as 
first  suggested  by  the  writer;  and  a  diminished  elasticity  of 
pulmonary  tissue  caused  by  the  infiltration  in  the  lung  as  sug- 
gested by  Hofbauer  and  Holzknecht.  The  fact  that  the  di- 
aphragm phenomenon  is  found  very  early,  before  there  is  suf- 
ficient disturbance  in  the  elasticity  of  the  tissues  to  cause  it 
shows  that  some  other  explanation  must  be  adduced  for  it  in 
the  very  early  lesion.  Since  other  muscles  taking  their  origin 
from  the  same  segments  as  the  diaphragm  are  involved  equally 
early  in  the  motor  reflex,  this  suggests  itself  as  the  plausible  ex- 
planation. 

Some  operators  fail  to  confirm  William's  sign.  This  is  prob- 
ably partly  due  to  a  failure  to  understand  the  conditions  sur- 
rounding its  production.  Clinically,  the  diminished  motion  of 
the  chest  wall  may  also  be  determined.  Many  observers  have 
difficulty  in  detecting  it,  probably  because  of  a  failure  to  un- 
derstand the  normal  and  because  of  wrong  technic.  Careful, 
painstaking  inspection  and  palpation  of  the  bases  by  one  who 
has  studied  the  normal  respiratory  movements  of  these  portions 
of  the  thoracic  wall  will  rarely  fail  to  detect  departures  from 
the  normal.  If  the  motions  of  the  chest  wall  are  studied  both 
on  normal  and  forced  inspiration  some  departures  from  the  nor- 
mal will  be  found  universally  when  the  pulmonary  tissue  is  the 
seat  of  active  inflammation.  To  examine  this  portion  of  the 
chest  either  by  inspection  and  palpation  or  by  the  fluoroscope, 
there  should  be  no  constriction  of  the  waist  to  interfere  with  the 
normal  movements  of  the  parts;  and  the  patient  should  be  ex- 
amined on  both  normal  and  forced  respiratory  effort.  Some- 
times deficient  motion  will  show  on  normal  respiration  and  not 
on  deep  respiration  and  sometimes  the  reverse  is  true. 

In  discussing  the  interference  with  the  motility  of  the  di- 
aphragm it  is  well  to  call  attention  to  the  fact  that  diminished 


526  X-RAY  AS  AID   TO   DIAGNOSIS 

descent  of  the  diaphragm  may  be  due  to  pleural  adhesions  and 
certain   abdominal   conditions   interfering  with   its  movements. 

It  is  not  necessary  to  say  that  a  diagnosis  should  not  be  made 
on  the  disturbance  in  function  of  the  diaphragm  alone.  This  phe- 
nomenon when  found,  however,  calls  for  careful  examination  of 
the  pulmonary  tissue  in  order  to  discover  its  cause.  The  rationale 
of  its  production  is  made  plain  by  the  fact  that  the  central  tendon 
is  supplied  by  the  phrenics  innervated  by  the  third,  fourth,  and 
fifth  cervical  segments. 

The  stereoscopic  plate  is  undoubtedly  the  greatest  advance  that 
has  been  made  in  the  x-ray  of  the  chest  and  I  do  not  doubt  that 
careful  comparative  examinations  made  by  expert  clinical  diag- 
nosticians and  expert  x-ray  operators  will,  in  the  near  future, 
be  able  to  put  the  diagnosis  of  early  pulmonary  tuberculosis  on 
a  much  surer  basis  than  it  has  hitherto  enjoyed. 

Cases  Illustrating  Comparative  Results  of  Clinical  and  Stereo- 
scopic Examination. — The  comparative  results  of  clinical  exami- 
nations and  stereoscopic  plates  may  be  illustrated  in  the  follow- 
ing cases.  The  writer  analyzed  the  cases  from  the  clinical 
standpoint,  taking  into  account: 

1.  Clinical  history  and  symptomatology. 

2.  Motor  (spasm)  and  trophic  (degeneration)  disturbances 
in  the  neck  and  chest  muscles  including  the  diaphragm  (dimin- 
ished motion)  and  trophic  changes  (degeneration)  in  the  skin 
and  subcutaneous  tissue  over  the  chest  wall. 

3.  Changes  on  palpation,  percussion,  and  auscultation. 

4.  The  results  of  the  tuberculin  test. 

The  stereoscopic  plates  were  taken  and  read  by  Doctor  Albert 
Soiland  of  Los  Angeles.  The  diagnoses  were  made  independently 
and  then  compared. 

A  comparison  of  the  clinical  findings  with  the  x-ray  findings 
in  the  cases  will  show  a  remarkable  agreement  in  the  main. 

Case  2786. 

Female,  age  39  years;  family  history,  negative. 

Clinical  History. — Not  strong  as  a  young  girl.  Better  the  last  four  years 
except  for  a  severe  attack  of  tonsillitis  last  year,  for  which  the  tonsils 
were  removed.     Three  months  ago  began  to  cough  and  developed  enlarge- 


COMPARATIVE   PHYSICAL   AND   X-RAY   EXAMINATIONS 


527 


ment  of  the  left  anterior  cervical  glands.     Has  also  had  stiffness  and  pain 
in  the  left  knee  for  one  year,  the  exact  nature  of  which  is  not  known. 
She  has  the  following  symptoms. 


Toxic  Group. 


II. 

Reflex  Group. 


III. 

Tuberculous   Process 
per  se. 


Malaise 

Lack  of  endurance 

Slightly  disturbed  appe- 
tite 

Loss  of  3  pounds  in 
weight 

Temperature    99.8 


Slight  hoarseness  for  sev- 
eral months 

Tickling  in  larynx  at 
times  very  annoying 

Cough 

Pain  in  left  shoulder 


Bronchitis  for  three 
month's 


Physical  Examination. — Left  pupil  larger  than  right.  Left  sternocleido- 
mastoideus,  scaleni,  trapezius,  levator  anguli  scapulae  slightly  degenerated 
with  well  pronounced  spasm.  Left  side  lags.  Percussion  note  slightly  im- 
paired over  left  apex. 

Auscultation  shows  inspiration  slightly  roughened,  with  expiration 
slightly  prolonged  over  left  apex  anteriorly  and  posteriorly. 

Tuberculin  Test.— Von  Pirquet  test  (Koch's  Old  Tuberculin  full  strength) 
positive,  reaching  maximum  of  1  cm.  in  24  hours. 

Diagnosis. — Active  tuberculosis  of  the  left  apex. 

X-Eay  Findings. — 

Left  Side. — Apex  slightly   cloudy. 

Several  caseated  areas  in  hilus,  with  generalized  inflammatory  deposit 
near  same. 

Lower  lobe  shows  thickened  walls  of  an  old  healed  cavity. 

Bight   Side. — Apex  clear. 

Hilus  shows  a  moderate  degree  of  fibrosis  and  calcified  glands. 

Case  2643. 

A.  P.,  female,  age  6%  years. 

Clinical  History. — Patient  suffered  from  recurrent  attacks  of  cold  dur- 
ing second  and  third  years  of  life,  for  which  adenoids  were  removed  when 
eighteen  months  old,  and  again  when  two  and  a  half  years  old.  Patient 
was  free  from  colds  for  one  year.  When  four  years  of  age  had  whooping 
cough  which  was  mild.  About  three  years  ago  patient  took  a  cold  which 
resulted  in  a  severe  bronchitis.  Patient  had  considerable  temperature 
and  made  a  very  slow  recovery.  It  is  questionable  whether  there  was  a 
pneumonic  process  present  at  the  time.  Following  this  attack  the  patient 
suffered  from  bronchitis  for  two  months  or  more,  for  which  she  was  taken 
to  a  mild  climate  for  relief.  From  that  time  until  the  present,  the  pa- 
tient has  had  repeated  attacks  of  colds,  which  always  ended  in  bronchitis; 
and  from  which  recovery  was  slow.  At  the  present  time  the  patient  is  suf- 
fering from  one  of  these  attacks  of  bronchitis,  and  is  brought  for  examina- 
tion to  determine  the  cause  of  same. 

Physical   Examination. — Inspection   and  palpation  reveal   the   following: 

A  fairly  well  developed  child  with  the  exception  of  the  upper  portion 
of  the  chest,  which  is  decidedly  flattened,  being  more  markedly  so  on  the 


528 


X-RAY   AS   AID    TO   DIAGNOSIS 


right  than  on  the  left.  Not  only  is  the  chest  flattened,  but  there  is  some 
degeneration  of  the  soft  tissues  on  the  right.  There  is  no  increased  tone 
(spasm)  of  the  muscles.  Posteriorly  the  soft  tissues  are  also  slightly  de- 
generated over  the  chest,  but  not  markedly  so.  The  total  density  of  the 
chest  as  revealed  by  palpation  is  increased  over  the  entire  right  lung, 
which  shows  most  markedly  posteriorly. 

Percussion  also  shows  a  slight  increase  in  the  resistance  to  the  finger 
over  the  right  lower  lobe  posteriorly  and  the  upper  lobe  anteriorly,  the 
changes  being  more  marked  over  the  lower  lobe. 

Auscultation  reveals  a  diminished  respiratory  murmur  on  the  right  side. 
Inspiration   slightly  harsher   than  normal,   expiration   somewhat   prolonged. 

Tuberculin  Test. — Von  Pirquet  test  (Koch's  Old  Tuberculin  full  strength), 
very  slightly  positive.     Tuberculous  infection  present  but  not  active. 

Diagnosis. — Some  thickening  of  the  tissues  in  the  right  lung,  probably 
as  a  result  of  pneumonia  or  of  the  attacks  of  bronchitis  which  patient  has 
had  in  the  past;  probably  peribronchial  thickening.  No  active  inflam- 
matory condition  present. 

X-Ray  Findings  (See  Fig.  99).— 

Bight  Side. — Mild  degree  of  peribronchial  thickening  extending  from  hilus 
of  upper  lobe  into  apex. 

Middle  lobe  clear.  A  more  marked  infiltration,  extending  from  hilus 
of  lower  lobe  and  reaching  diaphragm,  the  surface  of  which  shows  an  in- 
flammatory  thickening. 

Left  Side. — Clear,  except  small  fibrous  infiltration  at  hilus  of  upper  lobe. 

Case  2851. 

Female,  age  26  years,  occupation — office  work. 

Clinical  History. — One  brother  ill  of  tuberculosis  at  the  present  time. 
Patient  was  delicate  until  fifteen  years  of  age,  since  which  time  she  has 
been  in  fair  health,  but  has  had  an  unusual  number  of  colds  from  which 
she  always  recovered  slowly.  She  has  had  the  ordinary  diseases  of  child- 
hood and  several  attacks  of  supposed  malaria.  For  the  past  two  or  three 
years  in  the  fall  she  has  found  it  necessary  to  take  a  vacation  in  order 
to  be  able  to  continue  her  work.  During  the  past  year  she  has  not  felt 
as  well  as  usual. 

She  has  now,  or  has  recently  shown,  the  following  symptoms: 


I. 

II. 

III. 

Toxic  Group. 

Reflex  Group. 

Tuberculous   Process 
per  se. 

Malaise 

Slight  hoarseness 

Protracted  colds 

Lack  of  endurance 

Tickling  in  larynx 

Loss  of  strength 

Dry  hacking  cough 

Nervous  instability 

Slight    digestive    disturb- 

ance 

Loss  of  a  few  pounds  in 

weight 

Feeling       o  f      increased 

warmth,  although  tem- 

perature not  increased, 

when  taken 

Fig.   99. — Peribronchial    thickening    in    a    child    six    and    a    half    years    of    age. 


COMPARATIVE   PHYSICAL  AND   X-RAY  EXAMINATIONS  529 

Physical  Examination. — Inspection  and  palpation  reveal  the  following: 
Chest  considerably  flattened  over  the  apices.  The  soft  tissues  show  a 
moderate  degree  of  degeneration  over  both  apices,  most  markedly  on  the 
right.  This  degeneration  includes  the  skin,  subcutaneous  tissue,  sterno- 
cleidomastoidei,  scaleni  and  pectorales  anteriorly  and  the  trapezii  and 
levator  anguli  scapulae  posteriorly. 

Aside  from  the  degeneration  which  is  noted,  the  pectoralis,  trapezius, 
and  levator  anguli  scapulae  on  the  right  show  slightly  increased  tone  (spasm). 
The  sternocleidomastoideus,  scaleni,  pectoralis  and  trapezius  on  the  left 
also  show  slight  increased  tone  (spasm). 

The  right  side  of  the  chest  seems  to  lag  a  little  more  than  the  left. 

This  degeneration  of  the  muscles  and  subcutaneous  tissue  indicates  a 
chronic  inflammation,  affecting  both  lungs,  particularly  the  upper  lobes, 
which  is  more  marked  on  the  right  side.  The  increased  tone  (spasm)  also 
indicates  activity  on  both  sides  at  the  present  time. 

Deep  palpation  elicits  increased  density  over  both  apices  and  over  the 
fourth,  fifth,  and  sixth  thoracic  vertebras  with  the  pulmonary  tissue  ad- 
jacent to  them. 

Percussion  shows  slight  impairment  of  the  note  and  increased  resistance 
over  both  upper  lobes,  being  about  equal  on  the  two  sides.  The  resonance 
over  the  fourth,  fifth,  and  sixth  thoracic  vertebras  is  diminished  and  the 
resistance  increased. 

Auscultation  over  the  right  lung  shows  both  inspiratory  and  expiratory 
notes  harsher  than  normal  above  the  third  rib  anteriorly  and  the  spine 
of  the  scapula  posteriorly.  Expiration  is  slightly  prolonged  and  here  and 
there  the  inspiratory  note  is  somewhat  rougher  than  normal.  Adventitious 
sounds  which  seemed  to  be  extrapulmonary  are  present  anteriorly  near  the 
apex.  On  the  left  side  particularly  the  auscultatory  note  is  slightly  rougher 
than  normal  in  the  first  and  second  interspaces  near  the  sternum  and 
above  the  spine  posteriorly. 

Tuberculin  Test. — Von  Pirquet  test  (Koch's  Old  Tuberculin  full  strength), 
positive  in  twenty-four  hours,  reaching  a  maximum  of  1x1  %  cm.  in  diam- 
eter; a  papule  in  the  center,  with  slight  redness  surrounding  it. 

Diagnosis. — Hilus  infection.  Chronic  infiltration  of  the  upper  lobe  on 
the  right  side  with  slight  activity.  Chronic  infiltration  upper  left,  not  as 
extensive  as  on  the  right,  with  some  activity. 

X-Ray  Findings. — 

Bight  Side. — Apex  on  inner  aspect  is  infiltrated  from  hilus. 

Lower  half  of  upper  and  entire  middle  lobe  show  diffuse  infiltration, 
with  peribronchial  thickening. 

Lower  lobe  generally  clear,  with  some  mediastinal  fibrosis. 

Left  Side. — Apex  clear. 

Lower  half  of  upper  lobe  slightly  involved. 

Lower  lobe  nearly  clear. 

Case  2573. 

Female,   age   24  years,   family  history — positive. 

Clinical  History. — Patient  first  consulted  me  February  10,  1915,  with  the 
following  history: 

After  birth  of  child  four  years  previously,  patient  felt  tired  and  unable 
to  do  her  work  without  fatigue,  and  became  markedly  neurasthenic.     Her 


530  X-RAY   AS   AID   TO   DIAGNOSIS 

appetite  was  fair,  although  not  normal,  lost  2%  pounds  in  weight,  noticed 
slight  tickling  in  the  larynx,  with  tendency  to  cough  at  times. 

Examination  at  that  time  revealed  a  slight  lesion  in  both  lungs,  more 
marked  in  the  right,  which  seemed  to  be  approaching  quiescence. 

She  Was  instructed  in  hygienic  living  and  asked  to  return  in  six  months 
for  reexamination,   or  sooner,  if  ill. 

My  second  examination  was  December  13,  1915,  ten  months  after  pre- 
vious examination.  Three  months  prior  to  this  examination  the  patient 
had  suffered  from  a  severe  cold,  followed  by  a  bronchitis  which  persists 
to  the  present  time.  At  the  present  she  is  suffering  from  the  following 
symptoms : 


I. 

Toxic  Group. 


II. 

Reflex  Group. 


III. 

Tuberculous   Process 
per  se. 


General    nervous    depres- 
sion 
Lassitude 
Lack  of  endurance 
Nervous  instability 
Temperature  99.8 


Hoarseness 

Slight  dry  hacking  cough 

Aching  in  right  shoulder 


Tuberculous    bronchitis 


Physical  Examination. — Inspection,  palpation,  and  percussion  reveal  the 
following: 

1.  Lagging  of  right  side. 

2.  Slight  degeneration  and  slight  spasm  of  the  sternoeleidomastoideus, 
scaleni,  trapezius,  and  the  levator  anguli  scapulae,  on  the  right  side. 

3.  Degeneration  of  the  subcutaneous  tissue  on  the  right  to  the  4th  rib 
anteriorly  and  the  middle  of  the  scapula  posteriorly. 

4.  Slight  degeneration  of  the  apical  muscles  and  the  subcutaneous  tis- 
sue on  the  left  side  near  the  hilus,  running  up  towards  the  apex. 

5.  Palpation  of  total  density  reveals  increased  resistance  over  both  apices 
and  the  interscapular  spaces. 

6.  Percussion  shows  slight  impairment  of  the  note  and  increased  re- 
sistance on  the  right  to  the  third  rib  anteriorly  and  to  the  spine  of  the 
scapula  posteriorly  and  in  the  interscapular  spaces  near  the  hilus  on  both 
sides. 

On  auscultation  the  inspiratory  note  is  slightly  rougher  and  harsher 
than  normal  over  the  right  apex  to  the  third  rib  anteriorly  and  the  middle 
of  the  scapula  posteriorly.  Breathing  on  the  entire  right  side  is  weaker 
than  on  the  left.  The  expiratory  note  slightly  harsher  than  normal  near 
the  hilus  on  the  left  side. 

Tuberculin  Test. — Von  Pirquet  test  (Koch's  Old  Tuberculin  full  strength), 
positive,  reaching   a  maximum   of  1  cm.  in  diameter  in  24  hours. 

Diagnosis. — Hilus  infection  with  extension  to  adjacent  tissues  on  both 
sides.     Right,  apical  infection.     Right  side  active.     Left  side  quiescent. 
X-Ray  Findings. — 
Bight  Side. — Apex  clear. 


COMPARATIVE   PHYSICAL   AND   X-RAY   EXAMINATIONS  531 

Middle  lobe  involved  in  an  acute  process.  Two  circumscribed  areas  of 
tissue,   apparently  necrotic   at  hilus  of  this  lobe. 

Lower  lobe  generally  clear,  with  exception  of  small  degree  of  fibrosis. 
Left  Side. — Apex  clear. 

Lower  half  of  upper  lobe  has  considerable  peribronchial  thickening. 
Lower  lobe  clear. 

Case  2789. 

Male,  coal  dealer,  age  44  years. 

family  History. — Two  brothers  died  of  tuberculosis.  Patient  associated 
with  one  of  them  for  a  time  during  illness. 

Clinical  History. — Syphilis  in  1908.  Never  showed  any  signs  of  ac- 
tivity after  disappearance  of  first  symptoms.  For  the  past  two  years 
patient  has  been  gradually  losing  strength.  Has  suffered  from  mild  symp- 
toms of  toxemia, — malaise,  lack  of  endurance,  gradual  loss  of  strength, 
nervous  irritability,  and  has  also  had  recurrent  attacks  of  slight  hoarseness. 

Physical  Examination. — Inspection  shows  that  the  left  side  of  the  chest 
lags.  Slight  spasm  and  marked  degeneration  of  the  sternocleidomastoideus, 
scaleni,  pectoralis,  trapezius,  levator  anguli  scapulae,  and  the  soft  tissues 
over  them  on  the  right  side.  On  the  left  there  is  slightly  increased  tone 
(spasm)  of  the  sternocleidomastoideus  and  scaleni  and  a  slight  degenera- 
tion and  increased  tone  (spasm)  of  the  trapezius,  and  levator  anguli  scap- 
ulae. The  fact  of  a  slightly  increased  tone  of  the  trapezius  and  levator 
anguli  scapulae  on  both  sides  is  somewhat  confusing,  but  history  elicits 
the  fact  that  the  patient  is  using  dumb-bells  for  fifteen  to  thirty  minutes 
each  day,  so  the  increased  tone  may  be  due  to  hypertrophy  from  work  in- 
stead of  increased  tone  of  reflex  origin. 

Deep  palpation  shows  increased  resistance  over  the  upper  portion  of  both 
lungs  anteriorly  and  in  the  interscapular  region  running  up  toward  both 
apices  posteriorly  and  over  the  fourth,  fifth  and  sixth  thoracic  vertebras. 

Percussion  reveals  slight  impairment  of  the  note  and  increased  resist- 
ance to  the  palpating  finger  near  the  hilus,  running  up  to  the  apex  on 
both  sides  anteriorly  and  posteriorly;  and  also  an  impairment  of  the  note 
and  resistance  to  the  percussing  finger  over  the  fourth,  fifth  and  sixth 
thoracic   vertebrae. 

Auscultation  shows  the  inspiratory  note  to  be  slightly  rougher  and  slightly 
harsher  than  normal  near  the  sternum  and  running  up  to  the  apex  on  the 
left  side,  the  same  posteriorly  from  the  apex  down  to  the  middle  of  the 
scapula.  The  sounds  are  accompanied  by  a  sensation  of  stickiness  and 
some  adventitious  sounds  in  the  nature  of  clicks  that  seem  superficial. 
On  the  right  side,  above  the  third  rib  anteriorly  and  in  the  interscapular 
space  and  above  the  spine  posteriorly  the  breath  sounds  are  harsher  than 
normal. 

Tuberculin  Test. — This  was  not  given  because  patient  had  been  receiv- 
ing therapeutic  injections  of  tuberculin  for  some  time,  which  would  vitiate 
the  result. 

Diagnosis. — Thickening  of  tissue  about  the  hilus,  with  scattered  foci 
through  the  upper  part  of  both  lungs;  probably  quiescent  on  right  but 
more  recent  and  not  wholly  quiescent  on  left.  From  history  and  examina- 
tion impossible  to  tell  exact  nature.  Might  be  tuberculous  or  syphilitic  or 
both. 


532  X-RAY  AS  AID   TO   DIAGNOSIS 

X-Ray  Findings  — 

Bight  Side. — Apex  clear. 

Entire  middle  lobe  infiltrated  with  a  mild  degree  of  fibrosis. 

Lower  lobe  clear,  except  at  hilus. 

Left  Side. — Both  lobes  fairly  clear  with  exception  of  hilus  which  shows 
a  characteristic  fibrosis. 

Note. — There  is  a  cystic  degeneration  of  the  ribs  most  marked  in  the  right 
side  and  involving  the  posterior  articulations. 


CHAPTEB  XX. 

LABORATORY  METHODS. 

By  Joseph  Elbert  Pottenger,  A.B.,  M.D. 

The  special  pathology  of  tuberculosis,  in  favoring  the  develop- 
ment of  various  complications,  together  with  the  prolonged  course 
of  the  disease,  in  providing  greater  opportunity  for  the  entrance 
of  non-tuberculous  disease  processes,  places  a  great  responsibility 
upon  the  clinician  engaged  in  the  management  of  tuberculous 
patients.  Any  aid  which  may  be  obtained  from  laboratory 
methods,  enabling  him  to  make  earlier  diagnoses  and  better  prog- 
noses under  these  conditions,  will  be  gladly  accepted.  Laboratory 
methods  have  been  much  more  useful  in  diagnosis  than  they  have 
in  prognosis,  in  fact  their  relation  to  the  formation  of  the  latter 
judgment,  is  almost  entirely  confirmatory.  In  an  indirect  manner 
they  offer  assistance  the  value  of  which  cannot  be  overestimated. 
They  play  an  important  part  in  keeping  the  confidence  of  the 
patient  and  giving  him  assurance,  which  is  so  necessary  in  the 
management  of  his  case. 

The  choice  of  laboratory  methods  naturally  depends  upon  the 
stage  of  the  disease,  particularly  in  regard  to  the  examination 
of  sputum.  However,  there  are  certain  routine  tests  which  may 
be  made  at  regular  intervals  on  urine,  blood,  and  sputum,  if 
present,  regardless  of  the  stage  of  the  disease  which  fully  repay 
for  the  time  consumed  in  making  them.  Occasionally,  traces  of 
albumin  and  casts,  and  rarely  a  glycosuria  will  be  found,  in 
patients  where  no  history  of  such,  either  past  or  present,  may 
be  elicited. 

As  78  per  cent  of  all  patients  who  have  entered  the  sanatorium 
in  the  last  ten  years  were  in  the  third  stage  of  the  disease,  ex- 
pectoration was  usually  considerable  and  bacilli  plentiful,  afford- 
ing splendid  opportunity  to  study  the  most  characteristic  ma- 
terial associated  with  the  disease.  If,  then,  the  methods  of  anal- 
ysis described  under  sputum  seem  to  take  too  much  space,  as 


534  •    LABORATORY   METHODS 

compared  with  the  methods  described  under  urine,  blood,  and 
feces,  it  is  due  to  the  class  of  patients  that  come  to  us. 

SPUTUM. 

The  usual  method  of  measuring  the  twenty-four  hour  quantity 
of  sputum  in  hospital  and  sanatorium  practice  consists  only  in  a 
rough  guess  as  to  the  amount  of  pus,  bronchial  and  pharyngeal 
mucus  and  saliva  combined.  No  attempt  is  made  to  determine 
the  proportion  of  these  elements,  but  descriptive  terms,  such  as 
mucoid,  purulent,  and  mucopurulent  are  employed  in  describing 
the  solid  elements. 

It  occurred  to  us  that  a  more  exact  quantitative  determination 
of  some  of  these  elements  might  give  valuable  information  and  aid 
in  interpreting  the  many  complications  likely  to  arise  in  the 
course  of  the  disease.  The  total  nitrogen  determinative  was  tried, 
but  was  found  too  time  consuming  for  routine  procedure,  besides 
it  gave  no  information  as  to  the  relation  of  the  individual  ele- 
ments. As  is  well  known,  but  too  often  forgotten,  the  total 
amount  of  expectoration  varies  greatly  from  day  to  day,  due  to 
many  objective  and  subjective  influences ;  so  that  little  is  learned 
from  it  usually,  because  of  our  inability  to  determine  these  in- 
fluences. On  the  other  hand,  the  cellular  elements  are  fairly 
definite  in  amount  from  day  to  day  and  correspond  quite  ac- 
curately to  the  active  process  in  the  lung.  I  developed  a  technic 
for  the  measurement  of  the  volume  of  the  formed  elements  in 
1911  and  since  then  have  made  nearly  five  thousand  determina- 
tions. After  bacilli  have  once  been  found  there  is  no  other 
single  test  which  gives  more  information  with  as  little  labor. 

Our  routine  sputum  examination  is  made  every  four  or  five 
weeks,  just  previous  to  the  physical  examination,  and  consists 
in  the  accurate  measurement  of  the  twenty-four  hour  quantity, 
or  a  three  day  quantity  in  case  the  bacilli  are  known  or  are 
supposed  to  be  rare  or  absent,  the  cytological  examination,  the 
determination  of  the  sediment  volume,  rough  quantitative  albumin 
test,  the  search  for  bacilli,  and  their  morphological  classification, 
if  present. 

Collection  of  Sputum. — The  24  hour  specimen  of  sputum  is 
collected,  using  a  150  c.c.  glass  jar  with  metal  screw  cap,  which 


COLLECTION   OF   SPUTUM  535 

can  be  sterilized  at  170  to  180°  C.  The  patient  is  instructed  to 
start  at  8:00  o'clock  at  night  and  to  save  all  material,  whether 
or  not  he  thinks  it  comes  from  the  lungs,  throat,  or  nasopharynx, 
until  8:00  o'clock  the  next  night.  A  crystal  of  menthol  is  added 
in  warm  weather  to  deodorize.  Special  caution  is  given  to  avoid 
getting  food  particles  in  the  specimen. 

As  these  instructions  are  somewhat  at  variance  with  those 
usually  given  by  physicians,  I  wish  to  indicate  the  advantage 
which  they  secure  over  those  commonly  given, — to  save  "only 
what  comes  from  the  lungs."  Our  experience  leads  us  to  believe 
that  patients  generally  cannot  be  trusted  in  this  matter.  We 
constantly  meet  patients  who  state  positively  that  they  do  not  raise 
anything  from  the  lung,  but  only  from  the  throat  and  naso- 
pharynx, while  the  specimens  collected  as  above  described,  show 
typical  cavity  sputum,  with  plenty  of  bacilli.  In  quite  a  few  in- 
stances we  have  found  bacilli  in  sputa  where  they  had  not  been 
found,  although  they  had  been  searched  for  only  a  few  days 
before  by  other  laboratories.  This  is  attributed  to  faulty  in- 
structions to  the  patients  in  collecting,  rather  than  to  any  special 
superiority  of  technic. 

The  instructions  to  save  "only  what  comes  from  the  lungs" 
are  based  upon  the  fear  that  pus,  epithelium,  or  mucus  from  other 
parts  of  the  respiratory  tract  may  so  dilute  the  bacilli  that  they 
may  not  be  found  if  present  in  small  number.  This  danger  is 
much  overrated.  Postnasal  and  pharyngeal  mucus  in  simple 
catarrhal  conditions  is  destroyed  by  all  modern  methods  of  ex- 
amination, such  as  the  antiformin  or  the  fermentation  methods, 
with  their  various  modifications,  and  the  formed  elements  asso- 
ciated with  such  mucus  is  inconsequential.  A  small  amount  of 
saliva  mixed  with  the  sputum,  I  consider  advantageous,  as  it  aids 
the  fermentation  process  which  is  employed.  Only  rarely  do  I 
meet  a  case  where  it  seems  advisable  to  modify  these  instructions, 
on  account  of  the  presence  of  a  posterior  suppurative  rhinitis. 
In  such  case,  the  patient  is  taught  to  keep  such  material  from 
the  specimen. 

In  order  to  obtain  exact  results  it  is  absolutely  necessary  to 
avoid  the  two  hours  following  the  awakening  of  the  patient,  as 
the  time  at  which  to  start  and  stop  the  collection  of  the  specimen. 
The  time  for  expectorating  depends  largely  upon  the  position 


536  LABORATORY    METHODS 

and  activity  of  the  patient.  Most  patients  after  a  night's  rest 
feel  the  irritation  of  the  accumulated  sputum  as  soon  as  they 
awaken  and  change  their  position  in  bed  or  arise  on  their  feet. 
Within  the  next  hour  or  two  they  will  have  raised  all  that  has 
accumulated,  and  may  raise  little  if  any  from  the  lungs  during 
the  day.  Many  patients  raise  again  at  night  on  changing  position 
on  retiring.  Excluding  those  cases  with  massive  involvement, 
where  the  inflammatory  products  accumulate  rapidly  and  are 
raised  constantly,  it  is  probably  correct  to  say  that  on  an  average, 
three-fourths  of  all  the  solids  of  the  day's  expectoration  is 
raised  within  the  two  hours  following  the  awakening  of  the 
patient.  Now,  as  the  awakening  time  of  the  patient  varies 
from  day  to  day,  should  the  specimen  be  started  during  the 
period  of  active  expectoration,  there  is  great  likelihood  that  the 
supposed  twenty-four  hour  specimen  would  represent  more  or 
less  than  the  amount  secreted  in  twenty-four  hours,  depending 
upon  whether  the  patient  arose  earlier  or  later  on  the  second 
morning  than  he  did  on  the  first.  For  this  reason,  the  plan  of 
saving  from  night  to  night  is  preferable. 

Cytological  Examination. — A  study  of  the  formed  elements 
had  best  be  made  from  fresh  material,  though  in  comparing 
preparations  from  the  twenty-four  hour  specimen  and  from 
fresh  morning  expectoration,  I  have  been  unable  to  see  any 
difference  unless  fermentation  has  been  marked  in  the  former 
specimen.  Neutrophiles  from  tubercular  cavities  usually  stain 
poorly,  whether  in  fresh  or  older  specimens.  The  protoplasm 
stains  indistinctly,  the  nucleus  is  shrunken,  and  the  cells  often 
simulate  lymphocytes.  Their  appearance,  in  my  experience,  is 
in  marked  contrast  to  neutrophiles  found  in  the  sputa  of  certain 
acute  respiratory  infections.  Here  the  contour  of  the  cells, 
their  protoplasm  and  nuclei  are  all  distinct  and  well  differen- 
tiated. There  is  great  inequality  in  the  distribution  of  the 
various  cells  in  sputum.  Yellow  or  green  sputa  always  con- 
tains a  predominance  of  neutrophiles,  or  less  commonly  of  eosin- 
ophiles  as  in  asthma.  Gray  sputa  contain  epithelium,  both  pave- 
ment and  alveolar,  and  lymphocytes  in  predominance.  One 
should  take  several  distinct  particles  on  the  slide  and  examine 
them  separately,  since  a  particle  originating  from  an  old  healing 


CTTOLOGICAL  EXAMINATION  537 

cavity  or  from  the  region  of  a  tubercle  before  softening  has 
taken  place  is  likely  to  be  composed  chiefly  of  lymphocytes, 
while,  after  cavitation  has  taken  place,  neutrophils  predominate. 
One  can  hardly  make  a  satisfactory  differential  count  of  the  cells 
because  of  the  uneven  distribution.  A  rough  estimate  is  all  that 
can  be  expected.  Lymphocytes  are  likely  to  be  confused  with  cer- 
tain small  forms  of  epithelia,  and  certain  degenerated  mononu- 
clear neutrophiles,  and  only  continual  observation  will  give  con- 
fidence in  their  differentiation.  I  have  employed  Hasting 's  and 
Giemsa's  stains,  preferably  the  latter.  After  drying  the  smear, 
flood  with  the  stain  made  in  the  proportion  of  one  drop  to  1  c.c. 
of  distilled  water.  A  longer  time  is  required  to  stain  than  is  the 
case  with  blood  films, — 20  minutes  to  one  hour  giving  best  results. 

Fermentation  and  Determination  of  the  Sediment  Volume. — 
Having  measured  the  total  amount  of  sputum  for  24  hours  by 
direct  comparison  with  a  graduated  bottle  of  the  same  size,  the 
specimen  is  roughly  homogenized  by  shaking,  either  in  a  mechan- 
ical shaker  for  two  to  five  minutes,  or  by  hand.  Prolonged  shaking 
is  to  be  avoided,  as  it  interferes  with  sedimentation.  A  small 
portion  of  the  sputum  is  then  placed  in  a  graduated  cylinder 
or  any  cylindrical  tube  with  flat  bottom.  Homeopathic  vials  8 
to  10  cm.  long  and  of  10  c.c.  capacity  are  well  suited  to  this 
purpose.  The  cylinder  or  vial  is  then  tightly  corked  and  placed 
at  37°.  In  purulent  sputa,  the  mucus  is  completely  dissolved 
within  12  to  24  hours;  but  48  hours  is  required  in  the  case  of 
some  mucoid  sputa.  The  cellular  matter  then  settles  more  or  less 
compactly  to  the  bottom.  This  settling  continues  slowly  until 
about  the  fifth  day,  after  which  scarcely  any  change  is  observed, 
even  after  two  or  three  weeks.  The  proportion  of  sediment  to 
the  whole  amount  is  then  determined  from  the  graduate,  or  from 
the  vials,  by  means  of  a  rule  graduated  in  mm.  The  total  sediment 
for  the  24  hours  is  then  found  by  proportion.  This  reading  is 
called  the  gravity  sediment  volume. 

Formerly  this  reading  was  accepted  as  the  standard,  but  owing 
to  very  large  errors  met  with  in  about  25  per  cent  of  the  readings 
made,  I  recommend  the  use  of  the  centrifuge.  A  rather  high 
power  centrifuge  is  required.  At  present  the  standard  condition 
for  operating  the  centrifuge  is  30  minutes  at  2800  revolutions 


538  LABORATORY   METHODS 

per  minute,  with  a  tube  length  of  7.5  inches.  One  hundred  and 
three  findings  obtained  by  the  5-day  gravity  method  were 
compared  with  the  readings  after  centrifuging  the  same  tubes. 
It  was  found  that  on  an  average  the  reading  obtained  by  the 
gravity  method  was  reduced  to  51  per  cent  by  the  centrifuge 
so  that  the  approximate  factor  for  converting  the  centrifuge 
reading  into  the  gravity  equivalent  is  2.  Comparisons  between 
centrifuge  readings  taken  at  30  minutes  and  at  60  minutes  showed 
only  a  10  per  cent  reduction  in  volume. 

In  order  to  overcome  the  objection  to  such  a  method  of 
analysis  because  of  the  time  required,  I  have  employed  a  shorter 
and  more  practical  method  with  some  degree  of  success.  The 
specimen  is  placed  in  a  water  bath  at  52°  for  from  6  to  24  hours, 
and  then  centrifuged,  giving  readings  very  close  to  those  ob- 
tained on  duplicates  at  the  end  of  5  days  fermentation. 

The  determination  of  the  sediment  volume  is  recommended 
with  a  knowledge  of  the  well  known  errors  in  centrifuge  methods, 
when  quantitative  results  are  attempted.  The  error  is  under  10 
per  cent  in  one-half  of  the  specimens  examined;  between  10  and 
20  per  cent  in  one-fourth;  and  over  20  per  cent  in  the  remaining 
one-fourth.  On  the  other  hand,  there  is  a  great  difference  in  the 
amount  of  the  sediment  volume  as  met  with  in  different  patients, 
and  in  the  same  patients  at  different  times,  due  to  different  de- 
grees of  activity  of  the  disease;  so  that  a  considerable  error  may 
be  allowed.  My  readings  range  from  less  than  1  c.c.  to  105  c.c. 
The  latter  was  in  a  case  of  tuberculosis  complicated  with  pulmon- 
ary abscess.  The  sediment  volume  readings  may  be  placed  in  sev- 
eral fairly  definite  groups,  representing  the  degree  of  activity 
and  extent  of  involvement  in  the  lung.  Less  than  5  c.c.  is  found 
in  early  cases  without  bacilli,  or  if  bacilli  be  present,  without  gen- 
eral symptoms.  From  5  c.c.  to  15  c.c.  represents  a  moderate  de- 
gree of  activity  and  involvement.  Fifteen  c.c.  to  30  c.c.  indicates 
severe  activity,  massive  involvement,  or  both.  Above  30  c.c.  is 
rarely  met  in  uncomplicated  tuberculosis,  lung  abscess  being  the 
condition  met  most  commonly. 

Albumin  Reaction. — The  original  technic  of  Roger  for  the  de- 
tection of  albumin  in  sputum  does  not  readily  give  accurate 
quantitative    results;    for    one    cannot    conveniently    eliminate 


ALBUMIN   REACTION  539 

bubbles  of  air  which  are  more  or  less  mixed  with  the  sputum.  In 
order  to  properly  correlate  our  data,  fairly  accurate  relative 
quantitative  determinations  were  considered  essential. 

The  first  problem  to  be  solved  is  the  removal  of  the  mucus. 
This  is  accomplished  by  most  workers  in  the  following  manner: 
The  sputum  is  diluted  with  2,  3,  or  4  parts  of  .6  per  cent  salt  solu- 
tion and  thoroughly  shaken.  A  weak  solution  of  acetic  acid  (2  to 
5  per  cent)  is  added  drop  by  drop  until  the  nitrate  is  clear,  and 
does  not  give  a  cloud  with  the  acetic  acid.  The  nitrate  must  be 
neutralized  carefully  with  sodium  hydrate  before  testing.  At 
this  point,  the  worker  is  left  to  choose  such  method  as  he  may 
desire  for  the  albumin  test. 

Albumin  behaves  in  a  very  uncertain  manner  in  the  presence 
of  acetic  acid  as  a  demucinizer  unless  one  is  very  careful  to  neu- 
tralize. Even  then  there  appears  to  be  some  loss  of  albumin — the 
loss  increasing  as  the  time  and  amount  of  agitation  increases  be- 
fore filtering.  In  order  to  avoid  this  difficulty  I  have  relied  upon 
the  fermentation  process  as  the  most  convenient  demucinizer. 
Most  purulent  sputa  will,  after  6  hours  standing  at  37°,  filter 
slowly  but  clearly  through  good  filter  paper  without  previous  di- 
luting. I  have  made  comparisons  of  the  albumin  found  in  filtrates 
by  this  method,  with  the  albumin  from  filtrates  in  which  acetic 
acid  was  used  to  destroy  the  mucus,  and  have  found  that  the 
reaction  is  invariably  more  distinct  by  the  fermentation  method. 
There  was  an  estimated  increase  of  10  to  25  per  cent  by  the  heat- 
salt-acetic  acid  and  nitric  acid-contact  tests.  On  the  other  hand,  if 
fermentation  proceeds  too  far  the  albumin  is  split  and  there  is  a 
marked  loss  at  the  end  of  24  hours.  This  loss  continues  for  sev- 
eral days.  The  dilutions  were  made  accurately  by  weight  when- 
ever it  was  necessary  to  work  with  fresh  specimens  containing  air 
bubbles. 

The  following  method  may  be  used,  giving  relative  and  fairly 
accurate  quantitative  results:  Allow  sputum  to  ferment  to  the 
point  where  the  sediment  begins  to  settle.  Filter  the  supernatant 
liquid.  Draw  up  1  c.c.  of  the  filtrate  in  a  pipette  and  dilute  to 
10  c.c.  with  1  per  cent  salt  solution.  To  6  c.c.  of  the  dilution  add 
saturated  salt  solution  to  7.5  c.c.  After  mixing,  the  solution  is 
poured  into  a  half-inch  test  tube.     The  upper  portion  is  then 


540  LABORATORY    METHODS 

heated  to  boiling,  three  drops  of  glacial  acetic  acid  are  added,  and 
heat  is  again  applied.  The  strong  acid  is  used  because  it  favors 
the  development  of  characteristic  columns  descending  into  the  un- 
heated  portion.  A  weak  acid  does  not  do  this.  The  appearance 
of  these  columns  at  the  end  of  20  seconds  is  used  as  the  indicator. 
If  the  reaction  is  heavy  at  %0  dilution,  the  columns  appear  at 
once;  if  lighter,  they  appear  at,  say  5  or  10  seconds;  if  still  lighter, 
at  20  or  30  seconds,  etc.  One  can  soon  judge  from  the  intensity 
of  the  reaction  in  the  %o  dilution  just  how  much  further  it  should 
be  diluted  in  order  to  give  the  end  reaction  at  the  end  of  20  sec- 
onds. One  per  cent  albumin  gives  this  reaction  at  the  end  of  20 
seconds  in  a  dilution  of  approximately  %0o-  The  albumin  con- 
tent of  saliva  never  gives  the  reaction  beyond  Y10  dilution,  usually 
at  only  %  dilution.  Thus  a  positive  test  at  any  dilution  above 
y10  may  be  considered  pathological.  The  relative  24-hour  albumin 
content  is  determined  by  multiplying  the  dilution  recorded  by 
the  number  of  c.c.  of  sputum  in  the  24-hour  quantity. 

Studies  on  the  Distribution  of  Tubercle  Bacilli  in  Sputum  and 
Other  Conditions  of  Importance  for  Their  Demonstration.— Al- 
though many  advances  within  recent  years  have  been  made  in  the 
early  recognition  of  tuberculosis  before  bacilli  may  be  found  in 
the  sputum,  yet  there  is  a  considerable  percentage  of  borderline 
cases  in  which  doubt  as  to  diagnosis  prevails,  even  after  careful 
physical  examination,  tuberculin  tests  and  x-ray  plates  have  been 
made,  and  an  accurate  case  history  has  been  taken.  Consequently, 
it  is  imperative  to  develop  and  employ  such  technics  as  offer  us 
the  greatest  chance  of  finding  tubercle  bacilli  in  the  sputum. 

Of  the  many  known  technics  for  this  purpose,  little  is  known  of 
their  comparative  value,  and  until  some  method  is  developed  for 
their  accurate  standardization,  each  method  will  continue  to  have 
its  supporters.  Most  authors  in  proposing  their  technics,  have 
presented  the  claim  to  superiority  by  comparing  the  percentage  of 
positive  results  obtained  in  a  number  of  specimens,  with  the  per- 
centage obtained  in  fresh  smears  from  the  same  specimens.  The 
technic  which  is  likely  to  attract  most  attention,  then,  is  the  one, 
the  author  of  which  reports  the  highest  percentage  of  positive 
findings  as  compared  with  findings  in  direct  smears.  Such  evi- 
dence is  not  valid  in  establishing  the  relative  efficiency  of  technics 


THE   DISTRIBUTION    OF   BACILLI  541 

in  general,  unless  all  workers  search  for  the  same  length  of  time. 
The  time  spent  in  searching  specimens  is  rarely  mentioned  by 
writers,  although  it  is  the  easiest  factor  standardized.  It  is  not 
probable  that  workers  vary  greatly  in  the  speed  with  which  they 
examine  a  stained  preparation,  and  as  the  chance  of  finding 
bacilli  increases  with  the  time  spent  in  searching,  regardless  of 
the  technic,  it  seems  strange  that  this  factor  should  have  been 
almost  completely  overlooked. 

There  are  a  variety  of  other  factors  and  conditions  essential  to 
a  good  technic,  some  of  which  admit  of  approximate  standardiza- 
tion with  little  or  no  extra  demand  upon  the  worker,  except  the 
time  required  to  make  a  few  notes.  Uniformity  of  thickness  of 
preparation,  presence  or  absence  of  dust  particles,  scratches  on 
slides  and  artifacts,  nature  of  the  background  provided  by  the 
counterstain  and  the  penetration  of  stain,  all  contribute  to  the 
success  or  failure  of  a  technic.  More  important  perhaps  than  all 
other  conditions  combined,  is  the  uniform  distribution  of  bacilli 
in  a  preparation  to  be  examined.  The  varying  results  reported  by 
different  workers  employing  the  same  technic  are  undoubtedly 
due  to  failure  to  appreciate  the  importance  of  these  little  details; 
and  there  has  been  too  much  tendency  to  credit  the  "personal 
equation"  with  the  resultant  successes  or  failures. 

The  following  pages  set  forth  the  result  of  an  inquiry  into  the 
importance  of  some  of  these  conditions.  This  work  was  done 
entirely  by  daylight,  and  the  time  of  search  was  15  minutes  for 
each  preparation.  The  mechanical  stage  was  employed  and  the 
distance  traversed  was  recorded.  A  total  of  120  specimens  were 
examined  and  classified  according  to  whether  they  contained  less 
than  5,  5  to  20,  20  to  50,  50  to  100,  and  100  or  more  dust  particles 
in  each  field.  It  was  found  that  the  average  distance  covered  in 
31  clean  preparations  was  13  cm.,  and  in  4  preparations  con- 
taining 100  or  more  particles,  the  average  distance  was  8  cm. 
This  is  a  very  appreciable  loss  of  efficiency.  It  is  also  a  condition 
very  trying  on  the  eyes. 

Maximum  penetration  of  stain  in  the  bacilli  is  not  always  easy 
to  secure.  There  are  a  number  of  influences  working  against  it, 
such  as  the  presence  of  food  particles,  especially  fat,  in  the 
sputum,  and  the  effects  of  heat  and  chemicals  used  in  the  process 
of  homogenizing  and  staining ;  so  that  however  careful  one  may  be 


542  LABORATORY   METHODS 

in  securing  standard  conditions  for  the  staining  of  preparations, 
such  as  uniform  degree  of  heat  and  definite  time  for  exposure  to 
stain  and  decolorizing  reagents,  there  are  still  marked  differences 
observed  in  the  staining  of  the  same  strain  of  bacilli  when  com- 
pared after  various  methods  of  treatment.  Bacilli  exposed  to  as 
low  as  1  per  cent  NaOH  for  a  short  time  show  lessened  penetra- 
tion of  stain. 

For  practical  purposes,  in  comparing  the  staining  of  the  bacilli 
under  different  conditions,  I  classify  them  into  three  groups, 
deeply  stained,  well  stained,  and  pale.  The  lines  of  separation 
are,  of  course,  somewhat  indefinite,  but  with  Spengler's  staining 
method,  to  be  described  later,  and  which  I  have  used  for  eight 
years,  I  have  obtained  more  uniform  results  than  I  had  obtained 
before  that  time  by  the  older  methods.  In  deeply  stained  bacilli 
met  in  the  thinnest  preparations  the  beads,  even  when  present, 
are  barely  visible  or  are  not  seen  at  all.  Passing  to  thicker  parts 
of  the  preparation  the  bacilli  become  narrower,  less  deeply 
stained,  and  the  beads  stand  out  prominently.  These  are  called 
well  stained  bacilli.  Still  thicker  parts  will  show  very  pale 
pink  bacilli.  These  are  called  pale.  I  never  make  a  diagnosis 
from  the  presence  of  pale  bacilli  alone,  but  call  them  ques- 
tionable. 

The  following  table  illustrates  the  comparative  chances  of 
making  a  diagnosis  in  a  specimen  if  the  time  of  search  were  1 
minute,  2  minutes,  5  minutes,  10  minutes,  and  15  minutes  re- 
spectively. The  specimen  was  selected  because  of  the  rarity  of 
bacilli  and  was  searched  for  two  and  one-half  hours.  Each 
bacillus  and  bunch  was  recorded  with  the  minute  during  which 
it  was  found.  The  preparation  was  made  after  fermentation  and 
shaking  for  10  minutes. 

In  order  to  simplify  the  mathematics  let  us  assume  that  at  the 
end  of  the  10th  period  or  the  150th  minute,  the  same  microscopic 
field  appeared  as  with  which  we  started.  We  will  then  have 
150  possible  consecutive  periods,  of  15  minutes  each,  to  consider. 
The  first  column  of  findings  represents  the  first  period.  The 
2nd  minute  up  to  and  including  the  16th  minute  represents  the 
second  period.  The  150th  minute  up  to  and  including  the  14th 
minute  represents  the  last  possible  period. 


THE  DISTRIBUTION   OF  BACILLI 


543 


TABLE  I. 


Detail  Findings  in  Sputum  with  Rare  Bacilli  Searched  for  Two  and  One- 
Half  Hours — Divided  into  Ten  Periods  of  Fifteen  Minutes  Each 

Min 

1st 

2nd 

3rd 

4th 

5th 

6th 

7th 

8th 

9th 

10th 

1.  .. 

2.  .. 

3.  .. 

4.  .. 

5.  .. 

6.  .. 

7.  .. 

8.  .. 

9.  .. 

10.  .. 

11.  .. 
12... 

13.  .. 

14.  .. 

15.  .. 

1 
1 
0 
0 
0 
0 
0 
0 
0 

1 

0 
0 
0 
0 
0 

0 
2 
1 
0 
1 
0 
0 
0 
0 
8 
0 
0 
0 

1 

0 

0 
0 
0 
0 
0 
0 
0 
1 
0 
2 
0 
1-1 
0 
0 
0 

0 
0 
0 
0 
0 
0 
1 
0 
0 
0 
0 
0 
3 
0 
0 

0 
0 
0 
0 
0 
0 
1 
0 
0 
2 
0 
0 
3 
1 
0 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
1 
0 
0 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

1 
1 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

1 

0 

1 

0 
0 
0 
2 
0 
0 
0 
0 

1 

0 

1 

0 
0 
0 
0 

0 
0 
0 
0 
0 
0 
0 

1 

0 
0 
0 
0 

1 

0 
0 

Inspection  of  Table  I  shows  that  at  least  one  bacillus  or  bunch 
of  bacilli  was  found  during  each  possible  consecutive  15  minute 
period.  Considering  possible  consecutive  10  minute  periods,  a 
diagnosis  was  made  in  139  and  no  diagnosis  in  11.  With  5  minute 
periods  bacilli  were  found  in  100  and  were  absent  in  50.  The  2 
and  1  minute  periods  were  positive  53  and  29  times  respectively. 


TABLE  II. 


Tabulation  of  Positive  and  Negative  Periods  of  1  Minute,  2  Minutes 
5  Minutes,  10  Minutes  and  15  Minutes  Each,  from  Data  Supplied  by 

Preceding  Table 


1 
minute 

2 
minutes 

5 
minutes 

10 
minutes 

15 

minutes 

29 

53 

100 

139 

150 

Negative  periods 

121 

97 

50 

11 

0 

Per  cent  chances  of  finding. . .  . 

19.3 

35.3 

66.7 

92.6 

100 

As  there  are  many  sputa  in  my  experience  which  contain  ap- 
proximately the  same  number  of  bacilli  as  the  one  above,  the 
time  of  search  is  evidently  of  much  importance.  This  is  further 
shown  in  the  following  summary  of  all  records  of  rare  bacilli 
in  which  there  were  one  or  more  minute  periods  during  which  no 


544 


LABORATORY    METHODS 


bacilli  were  found.  Table  III  presents  147  such  records  from  54 
different  patients.  One  hundred  and  nineteen  of  these  records 
were  made  from  preparations  after  fermentation  and  shaking  in 
a  mechanical  shaker.  Of  the  remaining  28  some  were  made 
from  sediment  precipitated  by  alcohol  after  shaking  fermented 
specimens  with  antiformin  of  15  to  20  per  cent  strength,  a  few 
after  shaking  fresh  sputum  in  the  shaker,  and  a  few  after  fer- 
mentation without  shaking. 

TABLE  III. 


Showing  Chances  of  Finding 
of  Time, 

Tubercle  Bacilli  Within 
when  Bacilli  are  Rare 

Various 

Periods 

Method  of  Preparation 

Number 
of  Sputa 
examined 

1 

minute 
period 

2 
minute 
period 

5 

minute 
period 

10 

minute 
period 

15 

minute 
period 

Fermented 

14 

8 

8 

13 

14 

14 

Fermented;     Shaken 
10-20  min 

119 

37 

58 

88 

110 

119 

Fermented;     Shaken 
with  antiformin 

3 

2 

2 

3 

3 

3 

Shaken    fresh    10-20 

9 

4 

5 

7 

9 

9 

2 

1 

2 

2 

Total 

147 

51 

73 

112 

138 

147 

In  choosing  a  time  standard,  in  searching  for  bacilli  for  diag- 
nostic purposes,  clinicians  will  vary  considerably  according  to  the 
importance  which  they  place  upon  the  presence  of  rare  bacilli. 
In  comparing  the  different  time  standards,  we  must  consider  the 
average  amount  of  time  consumed  for  each  additional  diagnosis 
made.  That  15  minutes  is  the  maximum  time  standard  and  that 
little  is  gained  in  searching  beyond  that  point  at  enormous  ex- 
penditure of  time,  is  shown  in  the  results  obtained  in  another 
series  of  120  specimens  which  were  found  negative  after  15  min- 
utes' search.  Thirty  of  the  preparations  were  examined  for  a 
second  15  minute  period.  New  preparations  were  made  from  13 
of  the  specimens  and  they  were  searched  for  15  minutes.  A  third 
series    of  77   preparations  was  made   after   treating  the   sedi- 


THE   DISTRIBUTION   OF   BACILLI  545 

ment  with  antif ormin,  and  examining  for  15  minutes.    Each  series 
gave  one  positive  result,  or  3  in  all. 

It  is  evidently  impracticable  to  prolong  the  search  to  30  min- 
utes, since  in  order  to  obtain  3  diagnoses  the  amount  of  time 
consumed  was  120x15  minutes,  or  30  hours  of  hard  labor;  that  is 
10  hours  for  each  diagnosis.  Rather  than  search  beyond  15  min- 
utes, these  detailed  studies,  particularly  as  shown  in  Tables  IX, 
X,  and  XI,  indicate  that  time  would  be  saved  by  calling  for 
another  specimen.  If  we  compare  the  10  and  15  minute  time 
standards,  as  shown  in  Table  III,  Ave  find  that  nine  additional 
diagnoses  were  made  in  favor  of  the  latter,  at  an  expenditure  of 
147x5  minutes,  or  735  minutes ;  that  is,  82  minutes  for  each  diag- 
nosis. In  the  same  way,  the  time  required  to  make  each  addi- 
tional diagnosis  obtained  in  10  minutes,  as  compared  with  5  min- 
utes, is  28  minutes;  in  5  minutes  as  compared  with  2  minutes,  is 
13  minutes;  and  in  2  minutes,  as  compared  with  1  minute,  is  7 
minutes. 

The  great  lack  of  uniformity  in  distribution  of  bacilli  in  sputum 
is  well  known,  but  apparently  quantitative  studies  have  not  been 
reported.  In  order  to  obtain  accurate  information  on  this  sub- 
ject, four  years  ago  I  arbitrarily  established  15  minutes  as  my 
standard  for  searching  a  preparation  before  calling  it  negative, 
and  have  continued  this  practice  until  the  present  time.  The  time 
was  determined  accurately  by  watch.  In  case  the  bacilli  were 
rare,  averaging  one  or  less  per  minute,  15  minutes  was  usually 
employed,  and  each  bacillus  or  bunch,  the  latter  expressed  by 
the  approximate  number  of  bacilli  contained  therein,  was  re- 
corded with  the  minute  during  which  it  was  found.  A  note  was 
made  also  as  to  whether  the  bacilli  occurred  in  the  same  field. 
Detailed  records  of  this  sort  have  been  made  of  which  Table  IV 
(A  and  B)  are  illustrations.  Further  studies  were  made  on 
strongly  positive  specimens,  to  ascertain  the  degree  of  bunching 
of  bacilli.  Five  hundred  free  bacilli,  with  the  accompanying 
bunches,  were  usually  counted,  requiring  from  5  to  10  minutes. 
Table  V  illustrates  the  form  in  which  the  detail  was  recorded. 

Counting  the  free  bacilli  by  hundreds,  we  obtain  an  idea  of  the  ac- 
curacy of  the  differential  count.  In  a  total  of  54  consecutive  differ- 
entials, 37  showed  a  probable  error  (computed  by  least  squares) 
within  ±  10% ;  the  remaining  17  exceeded  ±10%. 


546 


LABORATORY    METHODS 


TABLE  IV. 


Form  of  Record  Where  Bacilli  Are  Rare 


Minute 

Sputa  A  Bacilli 

Sputa  B  Bacilli 

1 . 

1 
0 
0 
0 
1 
0 

1 

1 

0 
0 

1 

0 
5 
1 

0 

2   

0 

3 

7 

4 

20 

5 

0 

6 

1 

7 

3 

8 

0 

9 

0 

10 

0 

11 

2 

12 

0 

13 

0 

14 

0 

15 

1-1 

0 

Total  Bacilli 

13 

33 

The  dash  over  the  findings  in   15  minute  sputum  A  indicates  that  they  were  found 
in  the  same  field  but  did  not  touch  each  other. 


TABLE  V. 

Form  of  Record  for  Recording  the  Distribution  of  Bacilli 


Free 
Bacilli 

Bunches  Of 

Bacilli  In 

2 

3 

4 

5 

6 

Etc. 

100 

15 

2 

36 

100 

18 

3 

1 

49 

100 

13 

5 

0 

2 

1 

57 

100 

18 

36 

100 

14 

2 

34 

Total 
500 

78 

12 

1 

2 

1 

212 

Total  Bunches 94 

Total  Bac.  in  Bunches 212 

Total  Bacilli 712 


The  summary  of  these  differential  counts  are  presented  in 
Tables  VI  and  VII.  The  former  presents  174  records  from  73 
patients,  in  which  bacilli  were  present  one  or  more  per  field. 
The  latter  presents  115  records  from  47  patients  in  which  bacilli 


THE   DISTRIBUTION    OP   BACILLI 


547 


were  less  than  one  per  field.  Most  of  the  sputa  were  shaken  fresh 
for  10  minutes  in  a  mechanical  shaker.  Some  others  were  shaken 
for  10  minutes  after  fermentation,  while  a  few  others  were  ex- 
amined after  shaking  by  hand.  Tables  VI  and  VII  show  no  ap- 
preciable difference  in  the  averages  after  the  various  methods  of 


TABLE  VI. 


Summary  of  Distribution  of  Bacilli  After  Different  Methods  of  Prep- 
aration Where  Bacilli  Were  More  Than  One  Per  Field 


Method  of 
Preparation 

Specimens 
examined 

No. 

bacilli 

free 

No. 
bacilli  in 
bunches 

No. 
bunches 

Total 
bacilli 

Total  free 

bacilli 
+  bunches 

Fermented, 
Rough  shake. . . 

19 

12250 

19052 

6407 

31302 

18657 

Fermented, 
Shaken  10  min. 

9 

5800 

9624 

2177 

15424 

7977 

Shaken  fresh 
5-10  minutes. .  . 

139 

69020 

50698 

18430 

118718 

87450 

Shaken  fresh 
by  hand 

7 

4625 

5034 

1585 

9659 

6210 

Total 

174 

91695 

84408 

28599 

175103 

120294 

1.455 

TABLE  VII. 


Summary  of  Distribution  of  Bacilli  After  Different  Methods  of  Prep- 
aration Where  Bacilli  Were  Less  Than  One  Per  Field 


Method  of 
Preparation 

Specimens 
examined 

No.  _ 

bacilli 

free 

No. 
bacilli  in 
bunches 

No. 
bunches 

Total 
bacilli 

Total  free 

bacilli 
-f-  bunches 

Fermented, 
Rough  shake  .  . 

20 

530 

1328 

311 

1852 

841 

Fermented, 
Shaken  10  min.. 

68 

1329 

2143 

676 

3472 

2005 

Shaken  fresh 
5-10  minutes. .  . 

25 

1183 

1359 

413 

2542 

1596 

Antif  ormin 

2 

20 

12 

6 

32 

26 

Total 

115 

3062 

4842 

1406 

7898 

4468 

1.768 

548 


LABORATORY   METHODS 


treatment,  except  that  a  few  of  the  fermented  specimens  in  both 
tables  were  selected  because  of  the  presence  of  bunchnig  to  an 
extreme  degree.  Consequently,  the  number  in  bunches  is  much 
greater  than  is  found  in  the  specimens  prepared  by  other  methods. 
From  Tables  VI  and  VII  it  is  noticed  that  the  ratio  between 
the  total  bacilli  and  the  combined  total  of  free  bacilli  and  in- 
dividual bunches  is  respectively  1.455  and  1.768,  which  in- 
dicates a  corresponding  loss  in  efficiency  in  finding  bacilli.  If 
complete  resolution  of  these  bunches  into  their  component  cells 
could  be  attained,  with  subsequent  thorough  homogenization,  the 
chances  of  finding  the  first  bacillus  within  a  certain  period  of 
time  would  increase  about  45  per  cent  and  77  per  cent  respec- 
tively. This  is  important  for  the  specimens  summarized  in  Table 
VII,  because  most  of  them  present  some  difficulty  in  diagnosis. 
Referring  to  Table  IV,  Sputum  B,  which  is  an  illustration  of  one 
of  the  specimens,  it  is  seen  that  With  complete  resolution  of 
bunches  there  would  be  33  chances  of  making  a  diagnosis  in  15 
minutes,  which  with  perfect  distribution  should  give  a  fraction 
over  2  bacilli  during  the  first  minute.  As  a  matter  of  fact  there 
are  only  5  chances  of  making  a  diagnosis — a  loss  of  85  per  cent 
efficiency,  due  to  bunching. 

TABLE  VIII. 


Showing  Solvent  Effect  oi 

Various  Reagents  Upon  the 
Wax 

[nterbactllary 

Free  Bacilli 

Bunches 

Bacilli  in 
Bunches 

1000 
1000 
1000 
1000 
1000 
1000 
1000 
1000 

310 
373 

269 
35 
65 

38 

42 
164 

2084 
1740 

Ether  2% 

850 

Xylol  10% 

76 

Ligroin  10% 

146 

Chloroform  10% 

Carbon  bisulphide  10% 

Antiformin  20% 

78 
101 

836 

Three  years  ago  I  conducted  some  preliminary  experiments  to 
determine  the  effect  of  various  solvents  upon  the  interbacillary 
wax,  with  the  view  of  setting  the  individual  bacilli  free.  A  fer- 
mented specimen  was  chosen  which  showed  bunching  of  bacilli 
to  an  important  degree.     The  sputum  was  shaken  3  minutes  in 


THE   DISTRIBUTION   OF   BACILLI 


549 


the  shaker  to  obtain  rough  homogenization.  To  various  portions 
were  added  reagents,  as  in  the  preceding  table.  All  portions  were 
then  shaken  for  20  minutes.  Differential  counts  were  then  made 
of  the  free  bacilli  and  bunches. 

The  table  shows  clearly  that  xylol  and  chloroform  secure  al- 
most perfect  resolution,  with  carbon  bisulphide  and  ligroin  next 
in  importance.  Ether  and  antiformin  are  far  behind  in  efficiency. 
Shaking  for  20  minutes  without  reagent  gives  only  slight  reso- 
lution. 

Further  studies  were  made  to  ascertain  the  chances  of  finding 
bacilli  on  any  particular  day  in  a  series  of  successive  daily  ex- 
aminations of  24  hour  specimens  from  patients  in  whom  bacilli 
had  previously  been  found  to  be  rare.  Three  separate  series  were 
studied  from  as  many  patients.  Fourteen  examinations  were 
made  on  the  first,  with  one  negative  result.  Seventeen  were  made 
on  the  second,  with  three  negative  results.  The  positive  findings 
in  these  two  patients  were  such  as  would  give  no  probable  diffi- 
culty in  making  a  diagnosis  by  methods  which  do  not  secure  so 
uniform  a  distribution.  The  third,  however,  because  of  his  pre- 
vious history  together  with  the  record  I  had  made,  seemed  to 
present  a  difficult  problem  in  diagnosis.  His  laboratory  record 
before  coming  to  the  institution  is  as  follows:  Within  three 
weeks  before  entering  the  sanatorium  he  had  saved  morning  speci- 
mens ten  different  times,  without  a  diagnosis  having  been  made. 
The  technic  used  has  not  been  ascertained.  "Within  three  days 
before  entering  a  few  bacilli  were  found  by  another  laboratory 
at  the  end  of  two  hours'  search.  My  record  of  this  case,  prior 
to  the  detailed  experiment,  is  as  follows: 


TABLE  IX. 


Oct.  26, 
1913 


3  day  spec. 

1  bac.  1st  min. 

2  bac.  15th 
min. 


Nov.  22, 
1913 


3  day'spec. 

Negative 


I)( 


1913 


3*day|spec. 

Negative 


Jan.  30, 
1914 


3?day  spec. 

2  bacilli 
15th  min. 


Apr.  2, 
1914 


3  day  spec. 
Negative 


May  10, 
1914 


3  day  spec. 

Negative 


Because  of  this  history  of  rare  bacilli  alternating  with  nega- 
tive results,  this  patient  was  chosen  for  the  experiment  indicated 


550 


LABORATORY   METHODS 


above.    The  record  of  daily  sputum  findings  for  the  27  successive 
days  was  kept  as  follows : 


TABLE  X. 


Record  of 

Daily  Findings  in 

Sputum  of  Patient,  With  Rare  Bacilli 

June,  1914 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

Bacilli 

1 

2 

1 

0 

1 

1 

0 

7 

0 

0 

0 

0 

0 

found 

2 

4 

1 

within 

1 

15  minute 

search 

Jult,   1914 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

Bacilli 

0 

1? 

1 

0 

0 

0 

0 

1 

0 

1-3 

0 

1 

0 

0 

found 

2 

2-1 

1-1-1 

within 

2 

1 

1 

15  minute 

2 

1 

1 

search 

1 

Figures   separated   by   hyphen   mean   that   the    bacilli   were    found   within    the   same 
minute  period,  but  not  in  the  same  field. 

The  above  table  illustrates  two  important  points ;  first,  the  dif- 
ficulty in  finding  bacilli  in  this  case ;  second,  the  superiority  of 
the  3  day  specimen  over  the  1  day  specimen  as  a  time  saver.  It 
has  been  my  uniform  practice  to  have  patients  save  everything 
for  a  period  of  three  days  in  cases  where  bacilli  have  never  been 
found,  or,  if  found  were  rare. 

Inspection  of  the  above  table  enables  us  to  tabulate  the  fol- 


TABLE  XL 


Showing  Relative  Percentage  Efficiency  in  the  Demonstration  of  Tuber- 
cle Bacilli  of  Twenty-four  Hour  and  Three  Day  Specimens 


Total 
Specimens 

Negative 

Positive 

Chances    of    finding 
bacilli  on  any  given 
examination 

24  hour 

27 

17 

10 

37.0% 

Possible  3  day 

25 

12 

13 

52.0% 

Distinct  3  day. 

9 

3 

6 

66.7% 

TECHNICS   FOR   THE   PREPARATION    OP   SPUTUM  551 

lowing,  showing  the  relative  efficiency  of  a  24  hour,  and  3  day- 
specimen.  We  may  represent  this  relative  efficiency  by  consider- 
ing (a)  all  possible  consecutive  3  day  specimens,  and  (b)  each  3 
day  specimen  as  distinct.  The  first  method  presents  the  series  18, 
19  and  20;  19,  20  and  21,  etc. ;  and  the  latter  method  the  distinct 
series,  18,  19  and  20 ;  21,  22,  23,  etc. 

In  the  other  two  patients  mentioned  above,  the  3  day  specimen 
would  have  given  100  per  cent  findings  in  both,  whether  consid- 
ered as  possible,  or  distinct  3  day  specimens. 

Technics  for  the  Preparation  of  Sputum. — The  choice  of  a 
technic  for  the  preparation  of  sputum  depends  somewhat  upon 
the  character  of  the  specimen  to  be  examined,  upon  whether 
other  tests  are  to  be  made,  and  upon  the  urgency  of  diagnosis. 
In  sanatoria  time  is  usually  of  less  importance,  so  we  may  em- 
ploy the  slower  but  more  certain  methods.  All  workers  are 
agreed  that  the  fresh  smear  is  inadequate  if  the  result  is  nega- 
tive. But  as  to  the  choice  of  the  next  method  to  be  adopted  no 
uniformity  of  opinion  exists. 

It  seems  to  me  that  the  most  sensitive  technic  must  secure 
the  following  ends,  each  capable  of  demonstration,  and  each  at- 
tained without  injury  to  the  bacilli:  (1)  resolution  of  all  bunches 
of  bacilli  into  free  independent  cells;  (2)  distribution  of  the 
bacilli  uniformly  through  the  cellular  matter;  (3)  maximum  con- 
centration of  bacilli.  The  importance  of  distribution  and  con- 
centration have  long  been  emphasized  by  workers;  but  I  am  not 
aware  that  any  one  has  called  attention  to  the  importance  of 
the  resolution  of  bunches. 

Ellermann  and  Erlandsen,  for  the  first  time,  demonstrated  by 
exact  quantitative  methods  the  degree  to  which  it  is  possible  to 
concentrate  bacilli  by  the  various  technics  in  use  at  that  time. 
Starting  with  the  theory  that  in  the  search  for  bacilli  concen- 
tration is  the  great  end  to  be  attained,  they  based  their  conclu- 
sions as  to  the  comparative  value  of  technics  upon  the  relative 
number  of  bacilli  found  in  unit  volume  of  sediment  obtained  by 
centrifuging  for  one  hour  at  uniform  speed.  Their  work  is  the 
first  serious  attempt  to  standardize  technics.  They  established 
beyond  all  doubt  the  importance  of  the  viscosity  and  specific 
gravity  of  the  material  to  be  examined  in  preventing  concen- 
tration by  means  of  the  centrifuge.     Their  method  of  analysis 


552  LABORATORY   METHODS 

secures  the  following  desired  ends:  Lowering  of  viscosity  to 
almost  that  of  water;  lowering  of  specific  gravity  to  1006  to 
1008;  almost  complete  solution  of  pus  and  other  formed  ele- 
ments. The  method  gave,  in  their  hands,  from  three  to  fifteen 
times  as  many  bacilli  as  were  found  in  the  smears  of  the  same 
thickness  made  by  other  methods.  They  homogenized  the  ma- 
terial used  for  comparison  by  prolonged  grinding  in  a  mortar. 

My  experience,  as  suggested  by  the  studies  above,  has  con- 
vinced me  that  of  all  single  ends  to  be  desired  homogenization 
is  by  far  the  most  important — more  important  even  than  con- 
centration. Ellermann  and  Erlandsen  avoided  the  necessity  of 
discussing  the  importance   of  homogenization,   by  assuming  it. 

It  must  not  be  forgotten  that  bacilli  in  sputum  are  extremely 
irregular  in  distribution;  one  unit  portion  containing  practically 
no  bacilli,  another  containing  thousands,  still  another  millions; 
and  yet  these  different  portions  may  be  quite  similar  in  appear- 
ance. Every  laboratory  worker  in  examining  fresh  smears  has 
searched  many  fields  in  some  specimens  without  result,  and  then 
suddenly  found  a  number  of  bacilli  lying  near  each  other. 
Concentration  is  not  the  important  point  in  this  instance.  In 
fact,  the  bacilli  are  too  concentrated.  If  they  were  uniformly 
scattered,  a  much  less  number  of  fields  would  need  be  searched 
in  order  to  find  a  bacillus.  Fortunately,  all  the  best  modern 
methods  secure  homogenization  to  an  important  degree  before 
the  centrifuge  is  used  for  concentrating;  but  the  centrifuge  gets 
credit  for  too  large  a  share  of  the  increased  efficiency  of  such 
technics.  By  far  the  greater  part  of  such  efficiency  is  due  to  the 
homogenization  attained  by  brisk  shaking  and  the  solvent  ac- 
tion of  chemicals. 

The  Direct  Smear. — In  my  own  practice  the  fresh  smear  is 
rarely  employed,  as  bacilli  have  been  found  in  all  but  a  small 
number  of  patients,  before  entering  the  sanatorium.  When 
called  upon  to  examine  fresh  material,  I  select  with  a  glass  hook 
a  small  portion  from  fifteen  different  parts  of  the  specimen,  add 
one  drop  of  one  per  cent  NaOH,  and  homogenize  by  drawing  one 
glass  slide  over  another  50  times.  A  drop  of  water  is  then  added 
and  thoroughly  mixed  with  the  material;  the  slide  is  tilted  and 
dried  on  an  oven  at  60°.  Slides  made  in  this  manner  give  ex- 
cellent distribution  of  bacilli,  and  materially  reduce  the  neces- 


THE   DIRECT   SMEAR  553 

sity  of  using  the  more  complicated  technics.  Of  late  one  drop 
of  xylol  has  been  added  with  the  sodium  hydrate.  The  resolu- 
tion of  bunches  determined  by  differential  counts  is  almost  as 
thoroughly  attained  as  with  xylol  and  the  mechanical  shaker. 

The  old  fermentation  method  of  Phillip  has  served  as  the 
basis  for  my  routine  methods.  He  observed  that  if  sputum, 
negative  on  direct  smear,  be  placed  at  37°  for  24  hours,  fermenta- 
tion takes  place,  the  mucus  is  destroyed  and  bacilli  are  often 
found  in  the  sediment.  It  was  formerly  considered  that  the 
bacilli  multiplied  in  the  incubator,  and  Nuttall  came  to  this 
opinion,  from  results  obtained  in  making  exact  counts.  He 
made  daily  counts  on  24  hour  specimens;  those  obtained  on  the 
first,  third,  fifth,  etc.  days,  were  counted  fresh,  and  those  ob- 
tained on  the  second,  fourth,  sixth,  etc.  days,  were  counted  after 
fermentation.  This  indirect  method  is  hardly  convincing,  un- 
less a  much  larger  number  of  counts  be  made  than  he  reported. 
His  reason  for  not  making  the  counts  on  the  same  specimen  when 
fresh  and  after  fermentation,  was  that  the  violent  shaking  neces- 
sary to  secure  homogenization  of  the  fresh  specimen,  might  so 
injure  the  bacilli  as  to  destroy  their  reproductive  power.  His 
counts  on  the  fermented  specimens  average  a  little  higher  than 
those  on  the  fresh  specimens.  I  have  made  counts  on  three  dif- 
ferent specimens  when  fresh  after  thorough  homogenization,  and 
again  on  the  same  specimens  after  fermentation;  the  first  was 
5  per  cent  greater,  the  second  4  per  cent  less,  and  the  third  7 
per  cent  greater,  after  fermentation  than  when  fresh.  These 
results  fall  within  the  range  of  the  probable  error  of  the  count- 
ing method,  so  that  there  is  no  evidence  of  growth.  On  the 
other  hand  there  may  have  been  slight  growth  had  the  experi- 
ment been  conducted  as  Nuttall  suggested. 

The  Phillip  method  has  not  come  into  general  use,  perhaps 
because  of  the  necessary  delay  before  making  the  preparation; 
although  it  is  considerably  superior  to  the  fresh  smear  method. 
I  adopted  it  years  ago  because  it  often  gave  positive  results 
when  the  fresh  smear  had  been  negative.  Its  superiority  over 
the  direct  smear  is  due  probably  almost  entirely  to  better  distri- 
bution of  bacilli. 

Impressed  with  the  importance   of  thorough  distribution  of 


554  LABORATORY    METHODS 

bacilli,  following  the  publication  of  Rickard's  article  advocat- 
ing the  use  of  the  mechanical  shaker,  I  have  employed  this 
method  almost  exclusively  on  all  doubtful  specimens  and  on 
those  specimens  from  patients  who  previously  gave  few  bacilli. 
On  account  of  the  lowered  viscosity  due  to  fermentation,  better 
distribution  is  obtained  than  on  fresh  specimens.  In  a  series 
of  81  specimens,  negative  after  15  minutes  search,  by  the  Phillip 
method,  8  were  found  positive  after  shaking  10  minutes  and 
searching  for  15  minutes.  This  is  a  very  appreciable  gain,  and 
cannot  be  accounted  for  by  the  advantages  offered  in  search- 
ing a  second  15  minute  period;  for  the  second  15  minute  period 
had  been  found  to  give  only  3  positives  in  a  total  of  120  speci- 
mens negative  for  the  first  15  minute  period. 

The  Mechanical  Shaker. — The  mechanical  shaker  breaks  up 
the  mucus  in  fresh  specimens  and  distributes  the  bacilli,  if  pres- 
ent, uniformly  through  the  specimen.  It  probably  does  not 
break  up  the  bunches  of  bacilli  appreciably  within  10  or  15 
minutes  shaking.  Differential  counts  of  free  bacilli  and  bunches 
after  20  and  40  minutes  shaking  show  a  slight  resolution  of 
bunches.  On  fermented  specimens,  I  have  compared  the  differ- 
ential counts  made  after  5  minutes  shaking,  with  those  made 
after  20  minutes  further  shaking;  the  counts  from  the  latter 
invariably  show  a  smaller  proportion  of  bacilli  in  bunches.  The 
chief  value  of  the  shaker,  however,  is  in  securing  the  uniform 
distribution  of  bacilli  and  bunches  throughout  the  specimens.  A 
study  of  my  records  of  rare  bacilli  shows  that  after  shaking 
the  occurrence  of  two  free  bacilli  or  bunches  in  the  same  field  is 
an  unusual  finding,  although,  two  or  more  may  lie  parallel  ce- 
mented together  by  the  interbacillary  wax.  This  definite  pic- 
ture after  shaking  gave  me  opportunity  recently  to  exclude  the 
positive  findings  in  a  specimen  as  a  contamination;  I  had 
searched  for  4  minutes  without  result,  and  suddenly  came  to  a 
single  field  containing  1  bunch  of  20,  2  pairs  of  bacilli,  1  bunch 
of  3,  and  17  free  bacilli.  The  bunches  and  free  bacilli  did  not 
touch  each  other  at  all.  Search  for  the  rest  of  the  15  minute 
period  failed  to  give  a  single  bacillus.  Such  a  picture  is  com- 
mon in  direct  smear,  but  in  over  160  detailed  records  which  I 
had  made  following  the  shaking  method,  I  had  never  seen  such 
poor  distribution  before.    The  findings  were  surely  a  contamina- 


THE    MECHANICAL   SHAKER  555 

tion,  probably  from  a  droplet  of  bacillus  laden  material  from 
another  sputum  which  flew  on  the  slide  while  sterilizing  the  loop. 
On  identifying  the  specimen,  it  was  found  to  come  from  a  pa- 
tient who  had  given  a  negative  result  at  the  previous  examina- 
tion, and  in  whom  bacilli  had  never  been  found  before.  A  new 
specimen  was  collected  which  gave  a  negative  result.  In  this  way 
I  feel  that  the  shaking  method  affords  a  splendid  control  over 
possible  contamination  of  glassware  and  of  preparations  after 
they  have  been  made.  Chance  contaminations  must  surely  take 
place  occasionally  in  all  laboratories. 

The  shaking  method  has  been  modified  variously.  Thelinius 
shook  fresh  sputum  with  antiformin.  Kinyoun  proposes  a  tech- 
nic  which  probably  approaches  nearer  to  the  ideal  than  any  that 
has  yet  been  suggested.  His  routine  method  consists  in  adding 
1  c.c.  of  ligroin  to  the  specimen  and  an  indefinite  amount  of 
alkaline  hypochlorites.  The  mixture  is  then  shaken  5  to  10 
minutes  in  the  shaker,  and  transferred  to  the  centrifuge  at  low 
speed.  The  ligroin  carries  the  detritus  with  the  bacilli  to  the 
top,  forming  a  soapy  layer,  from  which  the  smear  is  made.  The 
advantage  in  this  method  is  that  it  combines  the  action  of 
ligroin  in  reducing  the  bunches  of  bacilli  into  their  component 
free  cells  with  the  thorough  distribution  attained  by  the  hypo- 
chlorites and  shaker. 

The  Ellermann  and  Erlandsen  technic  was  developed  as  the 
result  of  the  most  painstaking  inquiry  into  the  physical  char- 
acteristics of  sputum  and  the  modus  operandi  of  the  processes 
recommended,  that  has  appeared  in  the  literature.  Their  aim 
was  concentration,  rather  than  homogenization.  The  technic 
as  proposed  does  not  secure  as  thorough  homogenization  as  is 
obtained  with  the  shaker.  They  propose  a  modified  fermenta- 
tion method  followed  by  the  centrifuge.  The  method  is:  To  1 
volume  of  sputum  add  y2  volume  .6  per  cent  Na2C03.  Mix.  Set 
at  37°  for  24  hours.  Pour  off  fluid.  Centrifuge.  Pour  off 
again.  Now  add  to  1  volume  of  sediment,  4  volumes  .25  per  cent 
NaOH.  Stir  thoroughly.  Bring  to  a  boil  and  centrifuge.  The 
method  gave  three  times  as  many  bacilli  in  the  same  amount  of 
sediment  as  did  the  Phillip  method. 

It  is  generally  agreed  that  sodium  hydrate  in  strong  solution 


556  LABORATORY    METHODS 

either  destroys  the  tubercle  bacilli  or  injures  them  so  that  they 
do  not  stain  as  deeply  as  when  fresh.  Even  with  the  low  per- 
centage of  sodium  hydrate  recommended,  I  have  not  been  able 
to  obtain  as  deeply  stained  bacilli  by  the  Ellermann  and  Erland- 
sen  method  as  are  obtained  in  fresh  smears  or  after  simple  fer- 
mentation of  the  same  specimens.  Preparations  by  the  Eller- 
mann and  Erlandsen  method  sent  me  by  other  workers  invariably 
show  a  marked  diminution  in  stain  penetration — far  below  my 
routine  standard.  The  same  is  true  of  all  the  antiformin  methods 
which  I  have  tried.  Another  disadvantage  in  these  methods  is 
the  concentration  of  dust  particles  which  interferes  materially 
with  morphological  studies.  The  dust  cell  found  so  commonly  in 
the  sputum  remains  intact  after  simple  shaking,  but  if  a  solvent 
is  used — sodium  hydrate,  hypochlorites,  etc. — the  cell  is  disin- 
tegrated and  hundreds  of  dust  particles  are  scattered  through 
the  specimen.     This  is  a  decided  disadvantage. 

The  Wet  Method  of  Making  Preparations. — In  making  slide 
preparations,  regardless  of  the  technic  in  preparing  the  material, 
there  is  a  universal  tendency  to  transfer  the  sediment  to  be  ex- 
amined in  as  dry  a  condition  as  possible  to  the  slide,  and  depend 
upon  distributing  the  material  uniformly  with  the  loop.  It 
is  impossible  to  get  preparations  of  uniform  thickness  in  this 
way.  The  method  which  I  use  is  to  add  one  or  more  volumes 
of  water  or  salt  solution  (or  one  per  cent  egg  albumen,  if  work- 
ing with  a  centrifuge  residue),  which,  when  thoroughly  shaken 
by  hand,  may  be  poured  out  on  the  slide.  In  this  way  the  particles 
settle  evenly  in  drying.  The  slides  placed  on  a  constant  tempera- 
ture bath  at  65°  are  tilted  laterally  in  drying,  so  that  the  film 
will  be  thin  on  one  side  and  thick  on  the  other;  an  ideal  section 
will  be  found  between  these  extremes,  for  searching.  Fermented 
specimens  rarely  peel  off  in  preparation,  unless  they  have  fer- 
mented for  several  days.  Sputa  from  lung  abscess  cases,  because 
of  the  small  amount  of  mucus  and  albumin  present,  are  the  only 
exception.  It  is  always  advisable  to  add  egg  albumen  to  washed 
centrifuged  residue,  as  all  mucus  and  albumin  native  to  the 
sputum  has  been  lost. 

Staining  of  Tubercle  Bacilli. — The  Ziehl-Neelsen  staining 
method  is  the  one  generally  employed.    The  stain  is  made  as  fol- 


STAINING  OF   TUBERCLE  BACILLI  557 

lows:  fuchsin,  1  gm.;  absolute  alcohol,  10  c.c;  5  per  cent  car- 
bolic acid,  100  c.c.  The  preparation  is  covered  with  the  stain 
and  heated  over  the  flame  until  the  boiling  point  is  reached. 
Some  advise  boiling  for  three  or  four  minutes,  adding  new  stain 
as  the  first  evaporates.  Should  the  specimen  become  dry,  it  will 
be  hard  to  decolorize  and  crystals  of  stain  will  be  precipitated, 
which  are  confusing  in  the  search  for  bacilli.  Staining  in  the 
cold  or  at  37°  for  24  hours  has  been  recommended.  Such  speci- 
mens are,  however,  much  more  difficult  to  decolorize  with  weaker 
acids  and  alcohol.  For  decolorizing,  a  number  of  reagents  may 
be  used  with  a  considerable  range  in  strength.  The  tendency 
has  been  to  use  acids  and  alcohol  as  strong  as  may  be,  without 
injuring  bacilli.  Nitric  acid  25  per  cent,  hydrochloric  acid  2 
per  cent,  either  alone  or  in  80  per  cent  alcohol,  and  sulphuric 
acid  10  per  cent  in  95  per  cent  alcohol,  are  employed  by  various 
workers.  If  acid  is  used  alone,  the  decolorizing  must  be  com- 
pleted with  alcohol.  For  counterstaining,  Loeffler's  methylene 
blue  is  almost  invariably  used  (30  c.c.  saturated  solution  methy- 
lene blue  in  alcohol,  100  c.c.  of  a  1  to  10,000  aqueous  potassium 
hydrate  solution). 

In  my  own  practice  I  rarely  use  any  of  the  above  modifica- 
tions. The  acids  in  such  strength  and  95  per  cent  alcohol  re- 
moves much  of  the  color  from  the  bacilli.  I  prefer  maximum 
penetration  and  retention  of  stain  in  the  bacilli,  even  though 
the  criticism  be  raised  that  there  is  considerable  likelihood  that 
other  acid-fast  and  alcohol-fast  organisms  occasionally  will  be 
present  because  of  the  weakness  in  strength  of  the  decolorizing 
agents.  I  have  followed  Spengler's  staining  method  rather 
closely.  He  heats  only  to  a  faint  stream,  which  represents  a 
temperature  of  60°  to  65°  C. 

The  smear  is  covered  with  Loeffler's  methylene  blue  y2  to  % 
strength,  allowed  to  remain  for  30  seconds  and  excess  poured 
off.  As  soon  as  dry,  flood  with  carbol  fuchsin  and  place  on  con- 
stant temperature  water  bath  at  65°.  Let  stand  3  to  5  minutes. 
Pour  off.  Do  not  wash.  Flood  with  Esbach's  reagent;  agitate 
for  10  seconds.  Add  1  drop  15  per  cent  nitric  acid;  agitate  10 
seconds.  Pour  off.  Decolorize  with  70  per  cent  alcohol.  Wash 
with  warm  water  between  applications    of    alcohol    if    desired. 


558  LABORATORY    METHODS 

Counterstain  weakly  with  Esbach's.  Wash,  off  excess  reagent 
and  dry. 

The  use  of  methylene  blue  is  to  stain  the  envelope  of  the 
bacillus  so  that  the  resultant  color  of  the  bacillus  is  not  pure  red 
as  by  Ziehl's  method,  but  a  deep  purple.  The  use  of  the  oven 
gives  uniform  heat  to  all  specimens — a  very  important  point  if 
comparisons  are  to  be  made.  Spengler  used  the  first  applica- 
tion of  Esbach's  as  a  mordant,  stating  that  the  bacilli  were  less 
likely  to  be  decolorized.  I  have  no  opinion  on  this  point,  but 
it  acts  as  a  diluent  for  the  nitric  acid  used,  and  in  many  speci- 
mens imparts  sufficient  color  so  that  the  final  counterstaining  is 
not  necessary.  The  special  features  of  the  technic  are  the  low 
heat  applied,  weak  nitric  acid  (not  over  1  to  2  per  cent)  and 
weak  alcohol;  and  finally  the  substitution  of  a  yellow  back- 
ground for  the  classical  methylene  blue.  Any  one  who  will 
employ  this  background  long  enough  to  accustom  the  eye  to  the 
change,  will,  I  believe,  never  return  to  methylene  blue.  Yellow 
is  a  better  contrast  to  red  or  purple  than  is  blue.  The  pus  and 
epithelial  cells  are  scarcely  seen,  in  marked  contrast  to  the  pic- 
ture when  methylene  blue  is  used.  Consequently  all  bacilli  stand 
out  at  a  glance  and  one  does  not  hesitate  to  determine  whether 
an  artifact  at  the  edge  of  a  cell  is  a  bacillus  or  not,  as  it  is  often 
necessary  to  do  when  methylene  blue  is  used.  One  can  search 
a  much  thicker  field  because  yellow  intercepts  less  light  than 
blue,  and  thereby  increase  the  chance  of  making  a  diagnosis  in 
less  time.  I  have  used  this  technic  in  staining  over  9,000  sputa 
in  the  last  eight  years,  and  employ  it  exclusively  for  routine 
work.  It  is  a  satisfaction  to  learn  that  others  are  slowly  adopt- 
ing the  counterstain,  at  least. 

With  this  method  one  secures  a  maximum  penetration  of  stain 
in  all  specimens  except  in  those  admixed  with  food  particles, 
as  previously  mentioned.  The  number  of  pale  bacilli  in  smears 
of  the  same  thickness  average  much  less  than  where  the  older 
method  is  used.  In  making  differential  counts  of  bacilli  to 
determine  the  index,  I  often  classify  them  according  to  the  in- 
tensity of  stain  as  deeply  stained,  well  stained,  and  pale.  These 
observations  are  made  in  the  thinnest  parts,  where  little  back- 
ground is  seen.  Pale  bacilli  rarely  exceed  5  per  cent,  and  then 
they  are  usually  found  in  bunches.    In  many  specimens  less  than 


GRAM   POSITIVE   FORMS   OF   BACILLI  559 

one  per  cent  of  pale  bacilli  are  found  in  500  studied.  In  practice 
I  never  make  a  diagnosis  from  pale  bacilli,  but  insist  on  the  pres- 
ence of  deeply  stained  and  well  stained  types.  This,  I  believe, 
anticipates  the  possible  criticism  that  other  acid-fast  organ- 
isms might  be  included. 

I  have  studied  seven  different  strains  of  smegma  prepared  and 
stained  as  described,  with  the  result  that  they  were  uniformly 
pale,  and  would  therefore  be  excluded  from  consideration  as 
tubercle  bacilli. 

Gram-Positive  But  Non-Acid-Fast-Forms  of  Bacilli. — The  in- 
teresting observations  of  Much,  from  which  he  concluded  that 
there  is  another  well  defined  form  of  the  tubercle  bacillus  which 
does  not  retain  the  stain  after  decolorizing  with  acid  and  alco- 
hol, promised  to  throw  new  light  upon  that  group  of  patients 
who  never  show  acid-fast  bacilli,  but  yet  present  all  the 
clinical  symptoms  of  tuberculosis.  Guinea  pig  inoculations  of- 
ten result  positively  in  these  cases,  yet  no  bacilli  are  found  by 
the  usual  stain.  Much  found  that  the  organisms  in  these  cases 
were  Gram-positive;  but  that  they  had  apparently  lost  their  en- 
velope, which  by  the  Ziehl  staining  method,  retains  the  stain. 

Preparations  of  lymph  glands  and  other  tissues,  in  which  he 
was  unable  to  demonstrate  the  acid-fast  forms,  were  injected 
into  pigs,  producing  tuberculosis;  he  was  able  to  recover  the 
acid-fast  tubercle  bacillus  from  the  diseased  organs  of  the 
animals.  Material  from  a  cold  abscess  in  which  acid-fast  forms 
had  not  been  found,  produced  typical  lesions  in  pigs  from  which 
he  recovered  acid-fast  forms.  Thirty  preparations  of  the  ma- 
terial were  stained  by  Ziehl  and  the  rapid  Gram  method  with- 
out result;  but  in  all  cell  remnants  were  demonstrated  fine  gran- 
ula  after  staining  24  hours  at  37°  with  methyl  violet. 

In  culture  tubes  the  only  growth  up  to  the  eighth  day  was 
of  the  Gram-positive  type;  thereafter  acid-fast  rods  were  found, 
showing  the  transformation  of  the  former  into  the  latter.  The 
stained  picture  is  that  of  several  fine  granules  in  linear  arrange- 
ment, indicating  that  they  are  joined  together. 

The  stains  recommended  are: 

Gram     I.     Analine  oil — gentian  violet      5  min. 
Lugol  solution  1  min. 

Decolorize  in  absolute  alcohol  and  clove  oil. 


560  LABORATORY   METHODS 

Gram    n.     Methyl  violet  B.  N.  10  c.c.  saturated  alcoholic  solution  in  100  c.e. 
2%  carbolic  acid  (heat  over  flame,  or  24-48  hrs.  at  37°). 
Potass,  iodide — iodine  solution  1-5  min.     3%  hydrochlorine  acid 
10  sec. ;  finally  with  equal  parts  acetone  and  alcohol. 

Gram  m.     Methyl  violet  B.  N.  as  above. 

Potassium  iodide— H,02  (5  gm.  K  I;  100  cm.  2%  H202  2  min.) 
Decolorize  with  absolute  alcohol. 

In  practice  the  difficulties  in  differentiating  the  Gram-positive 
forms  from  other  organisms  seems  to  be  the  chief  difficulty  in 
the  method.  If  using  the  method  for  the  examination  of  sputum, 
fresh  specimens  only  may  be  used  before  fermentation  with  growth 
of  other  organisms,  has  taken  place. 

Indirect  Methods  for  the  Demonstration  of  Bacilli. — In  case 
bacilli  are  negative  in  sputum,  pig  inoculation  may  be  tried. 
Suspected  sputum  may  be  shaken  with  a  one  per  cent  solution 
of  sodium  hydrate  to  demucinize;  or  treated  with  10  to  20  per 
cent  antiformin  and  an  emulsion  made  from  the  centrifuged 
product.  I  have  used  untreated  sputum  to  a  considerable  ex- 
tent. By  quickly  heating  to  55  degrees,  the  viscosity  is  markedly 
lowered,  and  the  fresh  material  will  pass  through  a  large  needle 
slowly  with  sufficient  pressure.  Injection  behind  the  shoulder, 
in  the  inguinal  region  or  into  the  peritoneal  cavity  is  the  usual 
procedure.  It  has  been  recommended  to  crush  the  lymphatic 
glands  before  injecting,  if  the  shoulder  or  inguinal  region  is 
chosen.  In  this  way  injured  glands  are  supposed  to  be  more 
likely  to  become  infected.  Intraperitoneal  inoculation  is  prob- 
ably used  the  most. 

The  pig  should  be  weighed  before  inoculation,  given  hygienic 
quarters,  and  weighed  again  at  death  or  at  the  time  of  killing, 
which  is  two  to  three  weeks. 

While  not  proposed  for  diagnostic  purposes,  Petroff's  method 
of  sputum  culture  offers  a  possible  substitute  for  pig  inocula- 
tion. The  culture  medium  consists  of  1  part  whole  egg,  1  part 
of  meat  juice,  and  gentian  violet  1  to  10,000.  It  is  based  on  the 
fact  that  gentian  violet  inhibits  the  growth  of  all  organisms 
found  in  sputum  except  the  tubercle  bacillus.  Infuse  500  grams 
of  beef  in  500  c.c.  of  15  per  cent  glycerine  in  water.  Squeeze 
in  sterile  press  24  hours  later.  Collect  in  sterile  beaker.  Sterilize 
eggs  in  70  per  cent  alcohol  or  hot  water.     Break  in  beaker. 


THE    NUMBER   OF   BACILLI  561 

Mix  thoroughly.  Filter  through  sterile  gauze.  Add  1  part  of 
meat  juice.  Add  sufficient  gentian  violet  to  make  1  to  10,000. 
Tube  in  3  c.c.  quantities;  inspissate  for  3  successive  days;  1st 
day  at  85°  until  solidified; -2nd  and  3rd  days  at  75°  for  1  hour. 

The  sputum  is  shaken  with  3  per  cent  sodium  hydrate  and 
placed  at  37°  for  20-30  minutes;  then  neutralized  to  sterile 
litmus  paper  with  normal  HC1.  Centrifuge  and  inoculate  residue. 
Petroff  obtained  cultures  in  69  cases  without  a  single  contam- 
ination. Six  of  these  positives  were  from  patients  who  had 
never  shown  bacilli  before. 

Number  of  Bacilli. — The  importance  of  the  relative  number  of 
bacilli  in  sputum  has  been  discussed  by  many  clinicians,  especi- 
ally as  to  its  value  in  prognosis.  Various  detailed  methods  have 
been  suggested  for  reporting  the  findings,  the  best  known  of 
which  is'  Gaffky's  scale.  In  view  of  the  fact  that  the  older 
technics  did  not  secure  homogenization  of  bacilli,  it  is  not  prob- 
able that  any  very  definite  information  has  been  obtained  by 
this  method  which  is  of  value  in  observing  the  individual  pa- 
tient. Most  of  the  estimates  have  been  made  from  single  speci- 
mens without  any  effort  at  thorough  homogenization.  In  a  gen- 
eral way,  however,  all  observers  agree  that  the  greater  the  rela- 
tive number  of  bacilli,  the  severer  the  process  and  the  graver 
the  prognosis. 

Nuttall  showed  years  ago  that  the  total  number  of  bacilli,  as 
determined  by  exact  methods,  does  not  vary  greatly  from  day 
to  day  in  the  same  patient.  I  made  daily  counts  of  bacilli  from 
one  patient  with  chronic  tuberculosis  with  but  few  symptoms, 
for  a  period  of  eleven  days.  The  total  bacilli  in  the  24  hour 
specimens  for  the  successive  days  were  as  follows:  128,  130,  133, 
83,  98,  131,  97,  118,  56,  103,  and  117,  expressed  in  millions 
of  bacilli.  With  the  exception  of  the  number  for  the  9th  day, 
56  millions,  the  totals  are  remarkably  close. 

Individual  exact  counts  were  made  on  24  hour  specimens  from 
forty-three  different  patients,  the  counts  ranging  from  one  hun- 
dred and  forty  thousand  to  one  billion  in  cases  of  recent  cavity 
formation  and  of  moderately  extensive  involvement,  and  from 
one  billion  to  ten  billions  in  those  with  massive  involvement; 
one  count  gave  thirty  billions.     These  counts  were  sufficient  in 


562  LABORATORY    METHODS 

number  to  confirm  the  earlier  work  of  others,  and  to  show  that 
considerable  importance  may  be  attached  to  bacillary  estimation 
provided  that  the  error  be  not  too  great.  It  is  of  course  im- 
practicable to  make  exact  counts  as  a  matter  of  routine  because 
of  the  time  consumed. 

My  method  of  estimating  the  number  of  bacilli  is  as  follows: 
Twenty-four  hour  specimens  of  sputum  are  homogenized  10  to 
20  minutes  in  the  mechanical  shaker,  either  fresh  or  after  fer- 
mentation. The  bacilli  are  by  this  means  thoroughly  distributed. 
The  number  of  deeply  stained  bacilli  per  field  is  estimated.  Well 
stained  and  pale  bacilli  are  ignored.  If  less  than  one  per  field, 
say  1  bacillus  in  5  fields,  the  number  recorded  is  %.  If  one  or 
more  per  field,  the  record  is  1,  2,  3,  5,  10,  20,  etc.  Now  it  is  evi- 
dent that  the  number  of  bacilli  per  field  depends  upon  the  rela- 
tive proportion  of  solids  in  the  sputum.  If  we  assume  a  con- 
stant total  number  of  bacilli,  the  number  of  bacilli  per  field  will 
decrease  as  the  amount  of  solids  is  increased;  or  the  number 
per  field  will  increase  as  the  amount  of  solids  is  decreased. 
In  making  this  statement  we  ignore  the  albumin  and  mucus 
content,  since  the  former  is  decanted  after  fermentation  and  the 
latter  is  destroyed  in  that  process.  The  relative  number  of 
bacilli  in  24  hour  specimens,  therefore,  may  be  determined  by 
multiplying  the  estimated  number  per  field  by  the  number  of 
c.c.  in  the  sediment  volume.  This  computation  corrects  the  well 
known  fallacy  where  only  the  number  per  field  is  estimated. 

Although  the  error  in  estimating  the  number  of  bacilli  per 
field  is  considerable,  such  error  is  allowable  when  we  consider 
the  great  variation  in  the  actual  numbers  of  bacilli  from  differ- 
ent patients;  and  there  is  still  a  good  opportunity  to  classify 
patients  based  upon  these  estimates.  The  error  should  not 
usually  exceed  100  per  cent. 

The  demonstration  of  the  tubercle  bacillus  in  sputum,  feces, 
or  urine,  remains  the  most  important  fact  in  diagnosis.  There 
are,  however,  certain  theoretical  objections  to  accepting  all  posi- 
tive findings  of  bacilli,  particularly  in  sputum,  as  indicative  of 
tuberculosis.  Here  arises  the  question  of  the  possibility  of  con- 
tamination of  the  secretions  by  bacillus-laden  dust,  particularly 
in  cities.    I  was  not  impressed  with  this  possibility  until  I  had 


THE   NUMBER   OF  BACILLI  563 

determined  by  accurate  counting  methods  the  numbers  of  bacilli 
found  in  24  hour  specimens  from  patients,  and  the  numbers  found 
in  smears  from  the  same  cases  within  a  definite  time  of  search. 
In  one  count,  280,000  bacilli  were  computed  for  the  total  specimen 
in  which  the  sediment  volume  was  5  c.c.  In  stained  prepara- 
tions only  10  bacilli  were  found  in  18  minutes'  search. 

Now,  if  we  suppose  that  the  number  of  bacilli  and  the  sedi- 
ment volume  were  correspondingly  reduced,  say  ten-fold,  we 
would  have  28,000  bacilli  in  y2  c.c.  of  sediment  volume,  with  the 
same  results  microscopically.  Further  we  might  reduce  the 
microscopic  finding  to  1  or  2  bacilli  in  18  minutes'  search,  which 
would  indicate  the  presence  of  only  2,800  and  5,600  bacilli  re- 
spectively. As  many  24  hour  sputa  contain  less  than  y2  c.c.  of 
sediment  volume,  1  or  2  bacilli  might  be  found  in  18  minutes, 
although  only  500  to  1,000  bacilli  were  present  in  the  whole 
specimen. 

As  to  the  possibility  of  contamination  from  bacillus-laden  dust, 
in  the  above  example  we  have  but  to  consider  the  following 
record:  24  hour  quantity,  45  c.c.;  sediment  volume,  8  c.c.;  total 
bacilli,  3V4  billion;  bacilli  per  field,  30.  This  report  was  from  a 
patient  with  chronic  tuberculosis,  without  temperature,  and 
walking  about.  There  are  thousands  of  persons  presenting  this 
picture  in  every  large  city,  part  of  whom  at  least  are  expectorat- 
ing on  the  streets.  Now,  if  the  8  c.c.  representing  the  sediment 
volume  above  were  dried,  it  would  weigh  about  one  gram;  and 
if  distributed  into  one  million  particles,  as  it  probably  would 
be  by  the  action  of  the  wind  and  passing  vehicles  if  expectorated 
on  the  street,  each  particle  would  contain  on  an  average  3,250 
bacilli,  and  would  weigh  only  %ooo  °£  a  milligram. 

Bacilli  of  such  small  number,  lodging  in  the  nasal  and 
bronchial  secretion,  would  be  demonstrated  by  our  modern 
methods  of  sputum  examination.  In  my  practice,  bacilli  occur- 
ing  in  the  sputum  of  unknown  cases  in  number  less  than  5  bacilli 
in  15  minutes  search  are  considered  doubtful  for  diagnostic  pur- 
poses. If  such  findings  are  found  in  a  second  specimen,  I  con- 
sider the  diagnosis  made. 

It  does  not  seem  that  the  results  from  pig  inoculation,  whether 
positive  or  negative,  conclusively  prove  the  point,  though  it  is  to 


564  LABORATORY   METHODS 

be  expected  that  many  if  not  all  of  such  bacilli  would  be  dead, 
due  to  the  action  of  sunlight.  On  the  other  hand,  pigs  have  been 
infected  with  as  small  a  number  as  ten  bacilli,  which  rather  in- 
dicates that  they  are  too  sensitive  and  may  develop  the  disease 
from  contaminated  material. 

For  diagnostic  purposes,  the  interpretation  of  positive  find- 
ings obtained  by  the  cultural  method  of  Petroff  must  be  made 
with  still  greater  reservation.  In  fact,  it  is  quite  probable  that 
there  is  a  practical  limit  to  the  sensitiveness  of  technics  for  the 
demonstration  of  tubercle  bacilli  for  diagnostic  purposes,  at 
least  in  sputum,  urine,  or  feces  where  opportunity  is  offered  for 
contamination;  and  if  the  more  sensitive  methods  are  used,  it 
must  be  with  the  knowledge  of  added  responsibility  in  interpreta- 
tion of  results,  if  found  positive. 

Morphological  Classification  of  Tubercle  Bacilli.— For  eight 
years  I  have  recorded  the  following  general  description  of  the 
bacilli  found  in  smear  preparations:  Number  per  field;  whether 
extra  long,  medium  or  short;  extra  broad,  broad  or  narrow;  uni- 
formly stained  or  beaded;  deeply  stained,  well  stained  or  pale; 
bunched  or  free.  By  employing  the  initial  letter  of  each  descrip- 
tive term  a  complete  description  is  recorded  with  a  minimum  of 
writing.  The  three  mathematical  signs,  =,  <C,  ^,  indicate  the 
relative  proportions  of  the  characteristics  present.  =  is  used 
where  one  of  two  characteristics  is  from  40  to  60  per  cent  of  the 
other ;  <C  means  more  than  or  less  than,  and  denotes  that  the  lesser 
characteristic  is  from  20  per  cent  to  40  per  cent  of  the  greater; 
and  "C  means  that  the  lesser  is  from  10  per  cent  to  20  per  cent 
of  the  greater.  Less  than  10  per  cent  is  not  recorded.  The  fol- 
lowing illustrates  the  method  of  recording: 

50  per  field  1  +  <  1  <C  m  5  br  =  n;  b >- u-s;  d  -  s  <  w  -  s ;  bun  >  free. 

This  form  of  report,  while  not  very  accurate  for  the  individual 
case,  gives  considerable  information  in  the  aggregate.  The  dif- 
ficulty in  interpreting  such  findings  is  due  to  the  uncertainties 
incident  to  our  homogenizing  methods,  variable  penetration  of 
stain  and  to  the  well  known  difficulty  of  securing  smears  of 
uniform  thickness.  For  homogenizing,  the  mechanical  shaker  is 
indispensable.  As  to  penetration  of  stain,  there  is  considerable 
variation  with  which  bacilli  from  different  sputa  are  impreg- 


MORPHOLOGICAL   CHARACTERISTICS   OF  BACILLI  565 

nated.  This  is  often  noticed  when  two  preparations  are  placed 
on  the  same  slide  and  stained  together.  In  one,  the  bacilli  stain 
intensely  and  uniformly;  in  the  other  they  are  only  well  stained 
or  pale.  The  latter,  if  washed  with  ether,  on  restaining  will 
often  take  the  stain  as  intensely  as  the  other  specimen  does. 
In  such  sputa,  after  fermentation  one  will  usually  find  consider- 
able neutral  fat  floating  on  the  top  of  .the  supernatant  liquid. 
This  seems  to  account  for  much  of  the  defective  staining,  which 
is  likely  to  be  attributed  to  inherent  differences  in  bacilli.  This 
fat  is  usually  easily  traceable  to  food  particles, — butter,  milk, 
etc.,  where  the  patient  is  careless  about  cleansing  the  mouth 
after  eating. 

Even  after  all  other  technical  features  have  been  carefully 
carried  out,  such  as  thorough  homogenization,  uniform  tempera- 
ture during  staining,  definite  time  for  exposure  to  stain,  etc., 
one  may  obtain  quite  different  descriptions  from  the  same  speci- 
men unless  very  careful  to  choose  fields  of  the  same  thickness. 
Bacilli  which  appear  narrow,  beaded,  well-stained,  or  pale  in 
thick  fields,  are  broad  and  deeply  stained  in  very  thin  fields, 
and  the  beads  may  not  be  seen  at  all,  or  only  slightly  visible, 
being  masked  by  the  intense  staining  of  the  bacillary  envelopes. 

The  morphological  characteristic  which  is  most  free  from  er- 
ror in  recording  is  the  relative  length  of  the  bacilli.  From  50  to 
80  per  cent  of  all  tubercle  bacilli  in  all  cases  are  from  2  to  4 
microns  in  length;  the  remaining  50  to  20  per  cent  varying  greatly 
in  length.  All  may  be  less  than  2  p.  or  they  may  be  from  4  to 
10  fi.  in  length;  consequently,  the  average  length  of  bacilli  met 
with  in  different  sputa  shows  striking  variations. 

During  the  last  year  I  have  added  to  the  above  form  of  report 
a  fairly  accurate  classification  of  bacilli  based  upon  the  length, 
from  which  is  calculated  an  index  in  the  following  manner. 
Into  the  ocular  is  inserted  a  little  brass  frame  upon  which  is 
mounted  three  glass  beads  which  cast  shadows  of  2,  4,  and  6 
microns  upon  the  microscopic  field,  using  Bausch  and  Lomb 
eyepiece  1  inch  or  lOx,  objective  M.2th,  focal  distance  160  mm. 
(see  Fig.  100).  These  glass  beads  are  made  by  drawing  out 
very  fine  glass  filaments  in  the  flame.  They  are  then  fused  on 
the  end  in  a  very  small  flame,  preferably  from  an  alcohol  burner. 
They  are  then  standardized  with  the  stage  and  eye-piece  micro- 


566  LABORATORY   METHODS 

meters,  and  those  selected  which  are  of  the  desired  diameter. 
Unfortunately  the  manufacturers  do  not  make  their  oil  immer- 
sion lenses  exactly  of  the  same  magnification,  so  that  one  can- 
not use  the  device  in  different  microscopes  unless  the  ocular  and 
objective  systems  are  exactly  the  same.  I  have  three  B  &  L 
Y12  oil  immersion  lenses,  and  the  relative  magnifying  powers  are 
79.2,  75,  and  71.4.  This  results  in  a  variation  of  about  10  points 
in  index  in  comparisons  which  I  have  made,  between  the  first 
and  last  objectives.     There  would  be  a  great  advantage  if  the 


Fig.  100. — Device  for  classifying  tubercle  bacilli  according  to  length.  A,  B,  and  C, 
fine  glass  filaments  supporting  glass  beads  which  cast  shadows  of  2,  4  and  6  microns 
respectively,   upon   the   microscopic   field. 

method  could  be  carefully  standarized  so   that  a   given  index 
would  mean  the  same  regardless  of  the  instrument  used. 

Because  of  the  ease  with  which  the  device  may  be  broken, 
I  have  attempted  to  find  some  substitute.  A  special  disc  was 
made  by  the  manufacturer  upon  which  were  made  three  circular 
etchings  of  the  proper  size;  but  it  was  necessary  to  discard  the 
device  because  the  etchings  did  not  show  up  plainly.  With  a 
little  patience  I  believe  that  anyone  familiar  with  micrometry 


LENGTH   INDEX   OF   BACILLI  567 

can  manufacture  the  device  for  himself.  I  have  used  mine  for 
fifteen  months  without  breaking. 

Using  a  mechanical  stage  all  bacilli  that  pass  between  beads 
2  p.  and  6  /x.  are  classified.  This  can  be  done  quite  rapidly,  and 
in  most  preparations  it  is  not  necessary  to  orientate  the  beads, 
a  glance  being  sufficient  to  determine  whether  a  given  bacillus 
is  longer  or  shorter  than  the  diameter  of  a  certain  bead.  There 
are  some  preparations,  however,  that  give  considerable  trouble, 
in  which  the  greater  number  of  bacilli  are  so  near  2  fx.  and  6  fx. 
in  length  that  one  is  in  doubt  unless  the  bacillus  is  brought 
alongside  the  bead.  Very  thin  smears  only  should  be  used.  The 
bacilli  must  lie  absolutely  flat  and  not  tilted  as  we  find  in  thick 
fields.  Even  then  there  is  some  inaccuracy.  A  differential  count 
of  500  should  be  made  if  possible.  This  reduces  the  error  to  a 
small  figure. 

Length  Index  of  Tubercle  Bacilli. — The  index  is  derived  from 
the  differential  in  the  following  manner:  All  bacilli  less  than 
2  fx.  in  length  are  called  short  and  are  given  an  arbitrary  value 
of  1.  All  between  2  fx.  and  4  /x.  in  length  are  called  medium.  An 
arbitrary  value  of  2  is  assigned.  All  between  4  fx.  and  6  fx.  are 
called  long,  with  a  value  of  3.  All  longer  than  6  /x.  are  called 
extra  long  with  a  value  of  4.    A  count  of  100  is  the  basis. 


4 

3 

2 

1 

Differential 

Extra-long 

long 

medium 

short 

Inde 

Counts. 

8 

27 

72 

3 

260 

1 

64 

35 

166 

39 

61 

139 

The  index  determined  in  this  way  is  called  the  length  index 
of  tubercle  bacilli.  In  over  600  differentials  made  the  index 
varies  from  130  to  264, — about  75  per  cent  of  them  lying  be- 
tween 150  and  200.  The  index  cannot  be  made  safely  from  single 
specimens,  nor  from  unhomogenized  24  hour  specimens,  as  is 
shown  by  the  following  experiment:  A  patient  with  signs  of 
considerable  activity  was  instructed  to  separate  his  24  hour 
sputum  into  three  receptacles.  He  raised  35  c.c.  from  8 :00  p.  m. 
to  6  :00  a.  m.  ;  55  c.c.  from  6  :00  A.  m.  to  9  :00  A.  m.,  and  75  c.c.  from 
9 :00  A.  m.  to  8 :00  p.  m.  Two  direct  smears  were  made  from  each 
of  the   three   portions,   and   the   index  determined   from   each. 


568  LABORATORY    METHODS 

The  six  indices  were  180,  201;  185,  190;  187,  190.  Although  four 
of  the  indices  accord  splendidly,  a  variation  of  180  to  201  can- 
not be  allowed.  The  experiment  has  been  repeated  with  other 
patients  with  essentially  the  same  result. 

Comparisons  after  shaking  10  to  20  minutes  show  less  varia- 
tion between  duplicate  counts.  Two  series  of  duplicate  counts 
on  different  sputa  gave  the  following  indices:  214,  215;  165,  158. 
Several  series  of  counts  of  four  or  five  preparations  from  each 
specimen  gave  156,  155,  161,  160,  153;  202,  208,  210,  217,  214; 
223,  223,  221,  218.  Although  the  index  made  from  homogenized 
specimens  is  usually  more  accurate  on  the  average  than  when 
made  from  unhomogenized  material,  at  least  5  or  6  points  should 
be  allowed  for  error. 

URINE. 

The  value  of  routine  examination  of  urine  in  the  study  of  tuber- 
culous patients  is  not  appreciated  as  fully  as  it  should  be.  The  im- 
pression is  too  general  that  except  in  special  instances,  where 
some  non-tuberculous  complication  is  suspected,  urine  analysis 
offers  little  help  to  the  clinician  and  is  hardly  worth  the  time 
required.  Such  records  as  are  made  are  usually  determined  from 
single  specimens  which  may  give  quite  different  information  from 
what  would  be  obtained  if  twenty-four  hour  specimens  were  ana- 
lyzed. 

For  eight  years  I  have  made  an  analysis  of  a  twenty-four  hour 
specimen  from  each  patient  previous  to  the  regular  monthly 
physical  examination.  This  analysis  consists  in  the  determina- 
tion of  the  specific  gravity,  the  presence  or  absence  of  serum 
albumin,  globulin,  nucleo-albumin,  mucus,  reducing  bodies,  in- 
dican,  and  diazo.  For  the  last  two  years  the  urochromogen  test 
has  also  been  made  regularly.  Formerly  quantitative  chloride 
and  phosphate  determinations  were  made,  but  later  were  discon- 
tinued as  regular  tests.  Over  8,800  such  analyses  have  been 
made.  The  tests  which  have  been  most  useful  are  the  diazo  and 
indican  tests. 

Collection  of  Specimen. — Formerly  the  twenty-four  hour 
quantity  was  collected  from  morning  to  morning  according  to 
the  well  known  directions,  and,  although  the  instructions  were 


THE   DIAZO   REACTION  569 

carefully  given,  there  was  often  confusion  in  the  patient's  mind 
and  errors  were  common;  so  that  the  time  for  starting  and  end- 
ing was  changed  to  eight  o'clock  in  the  evening,  since  at  that 
hour  any  possible  error  in  voiding  more  or  less  than  the  proper 
amount  would  be  less  than  in  the  case  of  a  similar  error  in  void- 
ing the  more  concentrated  morning's  urine. 

There  is  no  great  objection  in  allowing  the  urine  to  stand 
over  night,  as  the  substances  tested  for  are  relatively  stable. 
Traces  of  albumin  may,  however,  be  formed  by  bacterial  autolysis, 
hence  the  presence  of  albumin  must  be  interpreted  with  this  fact 
in  mind.  A  few  drops  of  chloroform  are  added  to  limit  bacterial 
growth. 

The  Diazo  Reaction. — The  diazo  test  is  made  with  the  usual 
reagents. 

Sol.     I.     One-half  per  cent  sodium  nitrite. 

Sol.  II.     Sulphanilic  acid  5  gm. 

Hydrochloric  acid  50  c.c. 

Distilled  water  to  1000  c.c. 

In  making  the  test,  one-tenth  c.c.  of  Sol.  I  is  mixed  with  each 

5  c.c.  of  Sol.  II.  About  2  c.c.  of  urine  is  placed  in  a  test  tube 
one-half  inch  in  diameter,  and  to  it  is  added  an  equal  amount  of 
the  reagent.  The  mixture  is  shaken  briskly  to  develop  a  good 
foam.  One-tenth  volume  of  ammonia  is  now  added  and  a  pink 
color  in  the  foam  is  looked  for.  The  pink  is  often  masked  by  an 
admixture  of  brown.  In  such  cases  doubt  may  be  cleared  by 
adding  only  one-half  as  much  reagent  as  urine.  In  a  series  of 
tests  on  48  consecutive  urines  in  which  21  positive  and  10  doubt- 
ful reactions  were  obtained  by  using  equal  volumes  of  reagent 
and  urine,  sufficient  additional  results  were  obtained  by  using 
1/2  volume  reagent  to  1  volume  of  urine  to  make  29  positive  and 

6  doubtful  reactions  in  all.  "While  the  additional  advantage  given 
by  the  latter  proportions  of  reagent  and  urine  has  long  been 
known,  it  is  undoubtedly  overlooked  in  many  laboratories. 

When  the  diazo  is  positive,  the  relative  intensity  is  determined 
by  diluting  the  urine  and  making  the  test  again,  always  with 
equal  parts  of  the  reagent  and  diluted  urine.  The  dilution  at 
which  the  pink  is  just  visible  in  the  foam  is  recorded  as  the  de- 
gree of  intensity.     One  must  be  very  exact  in  making  the  dilu- 


570  LABORATORY   METHODS 

tion  and  in  measuring  the  urine  and  reagent,  otherwise  the  re- 
sults may  be  inaccurate.  In  over  2,000  positive  tests  found  in 
over  8,800  urines  from  1,500  patients,  diazos  were  found  com- 
monly ranging  from  a  doubtful  reaction  to  one-sixth,  rarely  to 
one-seventh,  one-eighth,  or  one-ninth.  As  the  diazo  is  usually 
more  intense  in  the  afternoon  than  in  the  morning,  positive  tests 
have  been  found  at  that  time  in  one-tenth  and  one-twelfth  dilu- 
tions. 

Although  the  diazo  reaction  has  been  known  for  over  thirty 
years,  individuals  will  differ  somewhat  in  deciding  whether  a 
given  test  is  positive  or  negative.  The  pink  foam  is  probably  the 
most  generally  recognized  criterion.  Normal  urines  give  a 
white  foam  if  fresh,  or  a  very  light  brown  foam  if  the  urine  has 
stood  for  some  time,  or  is  concentrated.  The  solution  below  the 
foam  ranges  from  light  yellow  to  dark  yellow,  sometimes  with 
a  slight  brownish  tone,  but  never  in  my  experience  does  it  as- 
sume a  reddish  tone  in  a  normal  urine.  When  doubt  exists  as 
to  the  presence  of  a  pink  in  the  foam,  I  call  the  reaction  a 
suggestion.  Patients  showing  such  doubtful  reactions  in  the 
twenty-four  hour  urine  will  nearly  always  show  a  distinct  diazo 
if  an  afternoon  sample  is  called  for.  These  doubtful  reactions 
always  show  a  reddish  tone  in  the  solution,  although  it  may  be 
partially  masked  by  admixture  of  brown. 

The  Urochromogen  Reaction. — In  announcing  his  permanganate 
test  for  the  urochromogen  body,  Weisz  considered  the  relative 
proportions  of  reagents  and  urine  to  be  of  little  consequence. 
This  fact  gave  it  great  advantage  in  his  mind  over  the  diazo  test, 
in  which  care  is  required  to  use  exact  amounts  of  reagent  and 
urine.  He  recommended  to  dilute  the  urine  roughly  with  two 
parts  of  water  in  a  test  tube,  and  add  three  drops  of  potassium 
permanganate.  The  development  of  a  yellow  color  was  con- 
sidered a  positive  test.  A  number  of  observers  following  these 
instructions  have  arrived  at  widely  different  conclusions  as  to 
the  relative  sensitiveness  of  the  urochromogen  and  diazo  tests, 
and  consequently  as  to  their  interpretation  for  purposes  of  diag- 
nosis and  particularly  prognosis  in  tuberculosis.  All  reports 
agree,  however,  that  the  urochromogen  is  met  more  frequently 
than  is  the  diazo.  Heflebower,  Gullbring,  Sinclair,  and  others 
found  it  from  two  to  three  times  as  often  as  the  diazo,   but 


THE  UROCHROMOGEN   REACTION  571 

Schaeffle  found  it  in  only  y±  more  cases  than  he  did  the  diazo. 
Others  found  the  relative  occurrence  of  the  two  reactions  lying 
between  these  extremes. 

From  the  simple  instructions  of  Weisz,  it  is  evident  that  two 
workers  may  make  their  tests  with  widely  different  proportions 
of  reagent  and  urine,  depending  upon  the  size  of  drop  of  reagent 
and  the  amount  of  urine  used.  As  it  seemed  that  this  might 
account  for  some  of  the  differences  shown  in  the  reports,  I  un- 
dertook a  detailed  study  of  both  urochromogen  and  diazo  in  a 
considerable  number  of  fresh  urines  from  normal  persons  and 
patients,  and  in  twenty-four  hour  specimens  from  patients.  The 
color  of  both  foam  and  solution  in  the  diazo  was  described.  The 
urochromogen  tests  were  made  in  a  series  of  five  tubes,  each  con- 
taining 5  c.c.  of  %  dilution  of  urine.  Using  one  tube  as  a  con- 
trol, to  the  four  tubes  remaining  were  added  successively, 
quantities  of  reagent  corresponding  to  5  drops,  3  drops,  2  drops 
and  1  drop, — this  being  the  probable  range  of  variation  em- 
ployed by  various  workers.  The  changes  of  color  were  recorded 
in  each  tube  at  once,  at  the  end  of  15  seconds,  of  30  seconds,  60 
seconds,  and  120  seconds.  If  either  the  diazo  or  urochromogen 
was  positive  on  first  trial,  the  urine  was  further  diluted  and 
the  test  repeated  until  the  dilution  was  found  in  which  the  pink 
disappeared  in  the  foam  and  solution  of  the  diazo  test,  and  the 
yellow  disappeared  in  the  urochromogen  test. 

From  this  work  it  was  found  that  yellow  reactions  indistin- 
guishable in  color  from  the  true  urochromogen  reactions  oc- 
curred in  the  majority  of  fifty-eight  normal  urines.  These  re- 
actions were  mostly  transient  and  their  permanency  depended 
directly  upon  the  amount  of  reagent  used.  Thus,  in  a  very 
small  number  of  urines,  the  yellow  persisted  beyond  30  seconds 
in  the  5  and  3  drop  tubes,  and  beyond  15  seconds  in  the  2  drop 
tube,  while  all  yellow  had  disappeared  in  the  1  drop  tube  at 
15  seconds.  For  this  reason  the  time  limit  for  transient  reac- 
tions was  established  at  60  seconds  for  the  5  and  3  drop  tubes,  at 
30  seconds  for  the  2  drop  tube,  and  15  seconds  for  the  1  drop 
tube.  Yellow  reactions  persisting  beyond  these  time  limits  were 
interpreted  as  positive  reactions.  In  the  two  series  of  94  fresh 
morning  urines  and  167  twenty-four  hour  specimens  from  pa- 
tients in  which  no  red  was  found  in  the  diazo  solution,  there  was 


572  LABORATORY    METHODS 

a  slight  tendency  for  the  yellow  to  persist  in  the  2  drop  and  1 
drop  tubes  beyond  their  respective  time  limits  for  normal  urines. 
In  fact,  1  positive  reaction  was  found  in  the  2  drop  tube,  and 
2  positive  reactions  were  found  in  the  1  drop  tube,  while  the  5 
and  3  drop  tubes  were  negative.  This  clearly  indicated  that  the 
lesser  quantities  of  reagent  were  more  sensitive  in  demonstrat- 
ing very  slight  reactions  than  were  the  larger  quantities  of  re- 
agent. In  four  of  the  above  urines,  showing  a  slight  diazo  reac- 
tion, the  urochromogen  was  recorded  negative  in  the  %  dilution 
of  urine,  in  all  tubes.  Diluting  the  urine  to  %  and'repeating  the 
test  gave  distinct  reactions  in  the  2  and  1  drop  tubes,  in  two  of 
the  urines,  and  questionable  reactions  in  the  other  two.  All 
these  urines  were  deep  yellow  in  color.  The  influence  of  the 
age  of  the  specimen  on  the  reactions  was  determined  by  com- 
paring the  reactions  obtained  on  fresh  normal  specimens,  with 
the  reactions  obtained  twenty-four  hours  later,  on  the  same  speci- 
mens. The  difference  was  insignificant,  showing  a  slight  loss 
in  the  permanency  of  the  yellow. 

From  these  facts,  the  following  standardization  of  Weisz's 
urochromogen  test  was  attempted.  Place  5  c.c.  of  %  dilution  of 
urine  (1  part  u.  and  2  parts  water)  into  each  of  two  test  tubes, 
selected  so  that  the  column  of  liquid  is  3.5  cm.  deep.  Hold  both 
tubes  over  a  white  background,  which  reflects  the  light  strongly 
and  place  0.1  c.c.  potassium  permanganate  (1:1000)  in  one  of 
them.  Shake  quickly  and  look  into  the  tubes  from  above. 
Record  any  increase  of  yellow  at  the  end  of  30  seconds  as  a  posi- 
tive reaction.  If  in  doubt  repeat  the  test,  using  only  .05  c.c. 
of  reagent  and  look  for  yellow  at  15  seconds.  If  still  in  doubt 
use  a  y5  or  %  dilution  of  urine,  and  repeat  the  test. 

Indican  Determination. — For  the  determination  of  indican  1 
have  employed  the  reagents  recommended  by  Robin,  adding  a 
quantitative  modification  which  may  be  carried  out  quite  ac- 
curately. 

To  20  c.c.  of  urine  add  2  c.c.  sat.  sol.  lead  acetate.  Filter. 
To  10  c.c.  filtrate  add  10  c.c.  Obermayer's  reagent.  Set  aside  to 
cool  about  30  minutes.  Add  20  drops  of  chloroform.  Shake 
30  seconds.  Let  stand  2  minutes.  Add  potassium  chlorate  solu- 
tion (34.6  gm.:1000  H20)  drop  by  drop,  shaking  twice  as  above, 


INDICAN   DETERMINATION 


573 


between  drops  until  no  blue  remains  in  the  chloroform.  One 
soon  learns  to  judge  as  to  the  approximate  number  of  drops  re- 
quired in  a  given  specimen,  so  that  in  a  chloroform  extract 
requiring  15  drops  to  decolorize,  nine  or  ten  drops  may  be 
safely  added  at  once.  Five  minutes  should  be  allowed  each  time 
for  the  full  effect  of  the  previous  drops,  before  new  quantities 
of  the  reagent  are  added. 

To  carry  out  the  test  conveniently  and  accurately,  I  have  used 
a  small  bulb  bottle  blown  from  glass  tubing,  of  about  30  c.c. 

n 


Fig.  101. — Bulb  and  pipette  for  convenience  in  making  quantitative  indican  determina- 
tions. A,  chloroform  extract  in  bottom  of  bulb;  B,  paramne  on  outer  wall  of  point  of 
pipette. 

capacity,  pouring  the  nitrate  into  it  from  a  graduate  and  then 
rinsing  the  graduate  with  the  Obermayer's  reagent.  The  drops 
are  added  by  means  of  a  standardized  pipette,  the  outer  surface 
above  the  point  of  which  is  covered  with  paraffine.  The  KC103 
thus  adheres  only  to  the  end.  Fifty  drops  equals  exactly  1 
c.c.  if  dropped  slowly  to  avoid  forcing  off  the  drop  by  rapid 
currents.  With  care  the  paraffine  need  not  be  replaced  for  two 
or  three  weeks,  although  if  the  drop  adheres  in  the  least  to  the 
wall  above  the  point,  it  will  be  too  large.  I  have  tested  this 
dropping  method  day  after  day  for  two  weeks,  under  diverse 


574  LABORATORY   METHODS 

atmospheric  conditions  and  have  found  that  the  variation  was 
less  than  1  drop  from  50  drops  to  the  c.c.     (See  Fig.  101.) 

The  result  of  a  given  test  is  expressed  in  the  number  of  c.c. 
of  KC103  which  it  would  take  to  decolorize  the  total  twenty- 
four  hour  quantity  of  indican  by  the  following  formula. 

Number  of  drop  X  10  X  Number  of  hundreds  of  urine. 
50 

Thus,  if  in  a  urine  of  1500  c.c.  it  takes  6  drops  to  decolorize 
the  indican  in  10  c.c.  of  nitrate,  the  application  of  the  formula 
would  be 

6x10x15  =  18. 
50 

The  average  elimination  of  indican  in  twenty-seven  normal 
persons  on  a  mixed  diet  was  found  to  be  fifteen  by  this  method. 
The  color  and  clearness  or  cloudiness  of  the  chloroform  extract 
should  be  noted.  In  normal  persons  the  bleached  extract  ranges 
from  no  color  at  all  to  light  shades  of  brown,  or  yellow  or  mix- 
tures of  both,  and  is  perfectly  clear.  With  stomach  and  bowel 
disturbances  the  extract  gives  deeper  shades  usually  with  the 
addition  of  red,  though  sometimes  dull  green  shades  are  found. 
The  extract  is  cloudy  in  the  majority  of  such  specimens. 

The  other  tests  mentioned,  require  little  notice  as  they  are 
well  known.  In  employing  Fehling's  solution  for  reducing 
bodies,  I  have  been  accustomed  to  indicate  the  slight  degree  of 
reduction  by  substances  other  than  glucose.  The  degree  of  re- 
duction is  indicated  by  the  sign  +  meaning  a  blue  green,  +  +  a 
pure  green,  and  +  +  +  a  yellow  or  colorless  reaction.  These  re- 
actions are  recorded  at  the  end  of  two  minutes. 

Tubercle  Bacilli  in  Urine. — Cases  of  tuberculosis  of  the  kid- 
ney or  bladder  rarely  come  to  us;  so  that  no  effort  has  been 
made  to  study  the  urine  for  tubercle  bacilli,  except  where  pus  is 
present.  I  invariably  examine  for  bacilli  in  such  cases.  The 
technic  employed  is  the  use  of  the  mechanical  shaker  followed 
by  the  addition  of  .25  per  cent  sodium  hydrate  according  to  the 
Ellermann  and  Erlandsen  technic,  if    concentration    is    desired. 

The  bunching  of  bacilli  in  urine  is  extreme  as  compared  with 
the  findings  in  sputum.    I  have  made  differential  counts  of  free 


TUBERCLE   BACILLI  IN   URINE  575 

bacilli  and  bunches  in  eleven  different  specimens  from  as  many 
patients.  The  largest  ratio  of  total  bacilli  to  the  number  of  free 
bacilli  and  individual  bunches  was  11.904;  that  is,  with  complete 
resolution  of  bunches  and  homogenization,  the  chance  of  finding 
the  first  bacillus  in  a  given  period  of  time  would  be  increased 
1090.4  per  cent.  The  average  ratio  of  the  11  specimens  was 
3.597,  showing  a  much  greater  tendency  to  bunching  than  is  ob- 
served in  bacilli  in  sputum  (see  Tables  VI  and  VII).  In  one 
case  I  had  an  opportunity  to  compare  the  ratios  found  in  the 
urine  specimen  and  in  caseous  material  from  the  kidney  after 
nephrectomy.  The  ratios  from  urine  and  kidney  were  respec- 
tively 2.833  and  2.718.  The  cavity  containing  this  material  did 
not  communicate  with  the  pelvis  of  the  kidney. 

From  these  observations,  it  might  be  suggested  that  for  diag- 
nostic purposes,  such  technic  is  indicated  as  secures  resolution 
of  bunches  and  thorough  homogenization.  This  is  found  in  the 
mechanical  shaker  after  5  per  cent  xylol  or  ligroin  has  been 
added  to  the  specimen.  In  one  specimen  in  which  5  per  cent 
xylol  was  added  and  shaken  20  minutes  almost  perfect  resolu- 
tion was  attained.  The  direct  smear  gave  a  differential  of  1000 
free  bacilli  to  4223  in  bunches;  shaking  with  xylol  gave  1000 
free  bacilli  to  58  in  bunches.  On  the  other  hand,  the  bunching 
is  so  characteristic  of  tubercle  bacilli,  that  one  wonders  if  it 
is  not  sufficient  in  itself  to  determine  a  positive  diagnosis,  and 
therefore  should  not  be  disturbed.  Smegma  bacilli,  in  my  ex- 
perience, do  not  show  this  arrangement.  Because  of  my  limited 
experience  in  these  cases,  I  hesitate  to  recommend  the  xylol  or 
ligroin  method  even  though  their  efficiency  in  resolution  is  almost 
perfect. 

BLOOD. 

Although  a  large  amount  of  work  has  been  reported  dealing 
with  blood  counts,  hemoglobin  estimation,  differential  counts, 
etc.,  the  opinion  is  more  or  less  prevalent  that  the  results  ob- 
tained do  not  justify  the  time  required  to  make  such  observa- 
tions, at  least  as  a  routine  procedure.  While  agreeing  with  this 
view  in  a  general  way,  I  have,  nevertheless,  made  these  deter- 
minations as  often  as  time  would  permit,  hoping  that  we  might 
be  able  to  place  a  better  interpretation  upon  them. 


576  LABORATORY   METHODS 

Practically  all  of  my  counts  have  been  made  within  thirty 
minutes  prior  to  the  midday  meal.  The  white  cell  count  made 
at  this  time  is  from  one-third  to  one-fourth  greater  than  after 
the  night's  rest  before  the  patient  has  stirred  about. 

The  technic  is  the  usual  one,  though  instead  of  using  a  steel 
lancet,  the  edges  of  which  are  always  rough,  at  least  microscopi- 
cally, a  capillary  glass  tube  is  used,  the  end  of  which  is  sharp- 
ened into  an  angular  point  by  inserting  a  small  pointed  instru- 
ment and  prying  first  to  one  side  and  then  to  the  other.  The 
glass  broken  off  leaves  a  lance  point  which  is  sharp  and  the 
edge  is  microscopically  smooth.  One  can  make  a  variety  of 
cutting  edges, — broad,  narrow,  long  or  short,  and  select  the 
one  which  the  conditions  of  the  skin  and  the  appearance  of  the 
surface  circulation  suggest.  This  method  of  puncture  is  far 
less  painful  than  the  old  method,  and  the  objectionable  pressure 
on  the  part  is  no  more  necessary  than  with  the  usual  method. 

As  the  hemoglobin  and  red  cell  counts  in  the  blood  of  the 
tuberculous  give  the  picture  of  a  simple  anemia,  I  have  not 
made  the  red  cell  count  unless  the  anemia  was  severe.  The 
hemoglobin  is  determined  by  the  Sahli  instrument.  The  white 
cell  count,  the  general  differential,  Arneth's  differential,  and 
certain  toxic  changes  in  the  neutrophiles,  have  been  considered 
of  most  importance. 

General  Differential. — For  the  purpose  of  making  differential 
counts  No.  1  cover  slips  are  used.  In  well  made  smears  one  may 
always  study  the  error  in  distribution,  while,  with  the  slide 
method,  there  is  an  unknown  amount  of  displacement  of  the 
larger  cells,  mainly  transitionals,  to  the  edge.  There  is  some 
displacement  with  cover  slips,  but  as  the  films  are  much  more 
uniform  in  thickness  than  can  be  obtained  by  the  slide  method, 
the  error  can  be  corrected.  The  first  hundred  cells  counted  at 
the  thick  edge  often  give  10  to  15  per  cent  of  transitionals,  while 
the  first  hundred  cells  counted  at  the  apex  of  the  film  gives 
from  0  to  5  per  cent.  So,  in  counting,  I  invariably  select  the 
middle  third,  avoiding  both  extremes.  Hasting 's  and  Giemsa's 
stains  are  used,  preferably  the  former.  Five  hundred  cells  are 
always  counted,  classified  as  neutrophiles,  basophiles,  eosino- 
philes,  large  mononuclear,  transitional  and  stimulation  cells. 


arneth's  index  577 

Arneth's  Classification  of  Neutrophils. — There  is  considerable 
difficulty  in  making  smears  suitable  for  Arneth's  classification. 
Even  in  the  best  of  films  where  there  are  from  one  to  three  thou- 
sand leucocytes  suitable  for  a  general  differential  count,  one 
may,  with  difficulty,  find  three  hundred  neutrophiles  satisfac- 
tory for  Arneth's  classification.  Only  the  thin  portions  of  the 
film  may  be  counted  lying  between  the  center,  where  the  cells 
are  more  or  less  crushed,  and  the  outer  thicker  margin.  The 
cells  must  be  spread  sufficiently  so  that  the  lobes  of  the  nuclei 
may  be  readily  recognized.  However,  in  the  best  of  films,  there 
are  10  to  15  per  cent  of  neutrophiles  that  defy  accurate  classifica- 
tion. I  always  rely  on  the  number  of  connecting  threads  in 
case  the  lobes  of  the  nuclei  overlap,  since  there  is  always  one 
thread  less  than  there  are  lobes.  I  have  not  obtained  as  low 
indices  on  normal  persons,  as  have  been  reported  by  some  ob- 
servers. I  am  inclined  to  believe  that  in  some  of  these  reports 
nuclear  buds  have  been  mistaken  for  lobes,  and  thus  the  index 
is  lower  than  it  should  be.  These  buds  are  common  in  neutro- 
philes from  the  blood  of  the  tuberculous  as  well  as  from  the 
blood  of  apparently  normal  persons.  They  are  connected  with 
the  parent  lobes  by  threads  indistinguishable  from  the  threads 
connecting  the  lobes  themselves,  except  that  they  spring  from 
the  side  of  the  lobes,  never  from  the  ends,  or  long  axis.  I  have 
counted  as  high  as  25  of  these  buds  in  100  neutrophiles,  which 
would  greatly  lower  the  index,  in  case  they  were  mistaken  for 
lobes.  Giemsa's  stain  is  somewhat  superior  to  Hasting 's  for 
Arneth's  counts,  but  as  it  is  less  suitable  for  general  differential 
counts,  I  have  not  used  it  to  as  great  an  extent.  My  average 
normal  indices,  as  computed  by  the  method  of  Bushnell  and 
Treuholz  is  57;  that  is,  the  sum  of  Classes  I  and  II,  plus  y2  of 
Class  III. 

Nuclear  and  Protoplasmic  Changes  in  the  Neutrophile. — 
Years  ago  Holmes  observed  certain  changes  in  the  neutrophile 
of  the  tuberculous  patient.  My  observations  confirm  in  part, 
what  he  described,  but  there  are  some  characteristics  which  ap- 
pear of  especial  importance.  These  changes  are  always  asso- 
ciated with  a  toxic  condition,  manifested  by  temperature  and 
other  signs  of  an  active  process.  They  consist  in  the  appearance 
of  small  granular  bodies  in  the  protoplasm,  approaching  black 


578  LABORATORY   METHODS 

in  color.     The  prominence  of  these  granules  is  designated  by 
the  signs  |+,  +,  +  +,  and  +  +  +,  the  first  indicating  very  slight, 
and  the  last  an  extreme  change,  where  the  granules  are  large. 
The  latter  is  invariably  found  in  patients  just  before   death. 
Coincident  with  this,  the  pink  tone  of  the  neutrophile  tends  to 
disappear,  and  the  protoplasm  approaches   the   basophilic    type. 
I    cannot   say   whether   these    dark,    almost   black    granules    are 
peculiar  to  tuberculosis,  as  I  have  not  had  sufficient  experience 
in  studying  bloods  in  non-tuberculous  infections.     But  records 
have  been  made  of  certain  differences  met  with,  in  a  case  of 
appendicitis,  one  of  typhoid  fever,  and    a    case    of    pernicious 
anemia.     In  none  of  these  would  the  granules  be  confused  with 
those  present  in  the  toxemia  of  tuberculosis.     The  case  of  ap- 
pendicitis later  came  to  operation  and  a  simple  catarrhal  con- 
dition was  found.     The  case  of  typhoid  ran  the  usual  course. 
This  protoplasmic  transformation  or  stippling,  is  never  present 
with  a  normal  Arneth  count.    But  a  marked  Arneth  change  may 
occur  without  the  protoplasmic  change.    As  young  cells  always 
show  greater  affinity  for  aniline  dyes  than  do  the  adult  cells, 
some  change  would  be  expected  in  neutrophiles  from  patients 
with  a  high  Arneth  index,  where  the  young  cells  are  increased 
in  the  circulation.     The  stippling  is  always  associated  with  a 
considerable  degree  of  toxemia,  with  more  or  less  constitutional 
symptoms,  while  a  high  Arneth  index  may  be  found  in  cases 
without  such  symptoms. 

FECES. 

Aside  from  the  search  for  tubercle  bacilli,  the  examination  of 
the  feces  from  tuberculous  patients  gives  little  or  no  informa- 
tion peculiar  to  the  disease;  consequently,  routine  examinations 
have  not  been  made  except  where  indicated  by  symptoms  point- 
ing to  bowel  complications. 

Tubercle  Bacilli. — In  examining  for  tubercle  bacilli,  visible 
particles  of  mucus,  if  present,  are  homogenized,  as  in  making 
direct  smears  of  fresh  sputum.  In  case  none  are  found  the  speci- 
men, after  grinding  in  a  mortar,  is  diluted  with  two  parts  dis- 
tilled water,  transferred  to  a  bottle  and  shaken  in  the  mechani- 
cal shaker.     After  allowing  the  coarse  undigested  particles  to 


TUBERCLE  BACILLI  IN  FECES  579 

settle,  a  smear  is  made  from  the  upper  more  finely  suspended 
material.  The  preparation  of  the  smear  and  staining  are  car- 
ried out  as  described  under  sputum,  except  that  absolute  alcohol 
is  substituted  for  70  per  cent  alcohol  in  decolorizing. 

In  1907  and  1908  a  study  was  made  to  determine  what  value 
the  routine  examination  of  feces  would  be  to  the  clinician.  The 
technic  employed  was  as  described  above.  The  time  of  search, 
however,  at  that  time,  had  not  been  standardized,  for  either 
sputum  or  feces,  so  only  a  guess  may  be  ventured  that  it  was  5 
to  10  minutes. 

In  order  to  exclude  bacilli  from  the  lung  as  far  as  possible, 
the  patient  on  entrance  was  cautioned  about  swallowing  his 
sputum,  and  5  days  were  allowed  for  previously  swallowed 
bacilli  to  pass  from  the  bowel.  At  the  end  of  this  time  the 
specimen  was  taken.  Two  hundred  and  sixty-nine  specimens 
were  examined  from  146  patients.  Bacilli  were  present  107 
times  and  absent  40  times  in  the  feces  of  68  patients  with 
bacilli  in  the  sputum,  and  they  were  present  4  times  and  absent 
118  times  in  78  patients  without  bacilli  in  the  sputum. 

Two  types  of  other  acid-fast  organism  were  occasionally 
found, — one  rather  short,  very  deeply  stained,  and  broader  than 
the  tubercle  bacillus;  the  other  very  pale,  and  of  rather  close 
relationship  morphologically  to  the  tubercle  bacillus.  The  first 
type  would  not  be  likely  to  confuse  one  who  is  familiar  with  the 
tubercle  bacillus  in  sputum.  The  latter  were  distinguished  by 
their  uniformly  weak  acid-fast  property;  and  I  did  not  consider 
them  tubercle  bacilli.  My  later  experience  justifies  this  con- 
clusion. On  the  whole,  I  do  not  consider  that  the  differentia- 
tion of  tubercle  bacilli  from  other  acid-fast  organisms  met  with 
in  the  feces  presents  any  very  difficult  problem,  if  care  be  taken 
to  secure  uniform  penetration  of  stain.  This  point  has  been 
discussed  under  sputum. 

The  presence  of  tubercle  bacilli  in  the  feces  seldom  points 
to  tuberculosis  of  the  bowels,  at  least  clinically.  It  is  highly 
improbable  that  patients  can  guard  against  swallowing  some  of 
their  sputum.  As  shown  in  the  work  above,  in  which  bacilli 
were  recovered  in  73  per  cent  of  all  specimens  from  patients  who 
showed  bacilli  in  the  sputum,  only  three  of  these  patients  gave 
evidence  of  intestinal  tuberculosis. 


580  LABORATORY   METHODS 

It  is  sometimes  strongly  advocated  to  examine  the  feces  from 
all  suspected  cases  where  sputum  cannot  be  obtained.  The  four 
diagnoses  made  from  examination  of  feces  in  my  series  appar- 
ently confirm  this  view,  since  in  two  of  the  four  cases  bacilli 
were  later  found  in  the  sputum.  But  had  the  same  care  been 
taken  in  the  collection  of  sputum  at  that  time  as  is  taken  now, 
it  is  probable  that  those  diagnoses  would  have  been  made  from 
the  sputum.  In  fact,  since  that  time  I  have  not  found  bacilli  in 
the  feces  in  a  single  instance,  in  which  they  were  not  also  pres- 
ent in  the  sputum. 

There  have  been  three  instances  within  the  past  five  years, 
in  which  patients  with  clinically  active  lesions  insisted  that  they 
had  no  sputum  on  first  examination;  but  at  succeeding  examina- 
tions plenty  of  sputum  with  bacilli,  was  obtained.  One  of  the 
three  intentionally  deceived  us  and  the  other  two  had  not  been 
properly  instructed.  Examination  of  feces  in  these  cases  might 
have  given  positive  results.  On  the  whole,  however,  the  routine 
examination  of  feces  for  diagnostic  purposes  will  be  found  a 
time-consuming  procedure  and  a  very  poor  substitute  for  thor- 
ough sputum  examination. 

It  is  sometimes  necessary  to  examine  the  feces  for  occult  blood. 
I  have  used  the  aloin  and  guaiac  tests  for  this  purpose.  The 
feces  are  ground  in  a  mortar;  a  small  portion  (1-2  gm.)  is  placed 
in  a  test  tube  and  1  c.c.  of  glacial  acetic  acid  added  and  shaken; 
from  3  to  5  c.c.  of  ether  are  now  added  and  shaken. 

A  portion  of  the  ethereal  extract  is  transferred  to  a  small  test 
tube  and  a  small  quantity  of  freshly  powered  guaiac  gum  is 
added  and  shaken;  five  drops  of  old  turpentine  (made  by  ex- 
posing chemically  pure  turpentine  to  the  air  for  several  weeks) 
are  now  added.  In  the  presence  of  blood  a  blue  to  tokay  color 
develops  at  the  point  of  contact  of  turpentine  and  extract;  or 
by  shaking,  the  whole  of  the  turpentine  takes  on  the  color. 

The  aloin  test  is  made  by  adding  old  turpentine  to  a  portion 
of  the  ethereal  extract,  and  then  6  to  10  drops  of  an  alcoholic 
solution  of  powdered  aloin  (a  pinch  of  aloin  in  ^  to  1  c.c.  of 
70  per  cent  alcohol).  The  development  of  a  bright  red  color 
within  5  minutes  time  at  the  line  of  contact  of  turpentine  with 
the  solution  indicates  the  presence  of  blood.    Beyond  this  time 


INTERPRETATION   OP  LABORATORY  FINDINGS  581 

limit  the   aloin-extract  mixture   tends  to   change  to  red   even 
though  blood  is  not  present. 

Patients  must  be  kept  off  a  meat  diet  for  three  days  previous 
to  the  collection  of  the  feces;  otherwise  either  test  may  react 
positively  to  the  blood  contained  in  the  meat. 

INTERPRETATION  OF  LABORATORY  FINDINGS. 

For  purposes  of  diagnosis  and  especially  prognosis,  the  inter- 
pretation of  laboratory  findings  in  pulmonary  tuberculosis  pre- 
sents a  difficult  problem.  Various  tests  have  been  brought  forth 
with  startling  claims,  only  to  be  discarded  entirely  or  to  be 
relegated  to  the  position  of  a  link  in  the  chain  of  evidence  upon 
which  the  judgment  of  the  clinician  is  based.  Arneth's  index, 
the  albumin  reaction,  and  the  diazo  have  a  similar  history,  il- 
lustrating the  truth  of  the  previous  statement.  Further,  if  we 
keep  in  mind  the  pathology  and  the  general  course  of  the  dis- 
ease, it  is  difficult  to  understand  why  we  should  expect  any  given 
test  to  supply  us  with  all  the  information  desired  in  forming  a 
judgment.  Such  opinion  may  be  formed  from  a  knowledge  of  the 
extent,  activity,  and  probable  duration  of  the  disease  process. 

The  findings  in  blood,  sputum,  urine,  and  feces  are  but  sec- 
ondary to  the  disease  process,  and  are  of  importance  only  as 
evidence  of  its  extent  and  activity  at  the  time  of  observation. 
Only  in  a  very  general  sense  can  this  information  be  of  prog- 
nostic value.  Nor  may  it  be  expected  that  this  unsatisfactory 
condition  will  be  remedied  until  more  delicate  serological  and 
chemical  methods  have  identified  the  primary  principles  condi- 
tioning infection  and  resistance  to  infection.  Probably  this  in- 
formation will  come  largely  through  increasing  knowledge  of 
the  internal  secretions,  and  cell  ferments.  Working  under  such 
limitations,  we  must  not  expect  too  much  from  the  interpreta- 
tion of  our  data.  The  making  of  diagnoses  a  little  earlier  and 
more  confidently;  the  more  certain  determination  of  the  nature 
of  the  complications  which  arise  in  the  course  of  the  disease; 
the  collection  of  data  which  at  best  is  only  of  limited  value  in 
establishing  a  prognosis;  the  accumulation  of  information,  which, 
though  of  little  or  uncertain  value  in  treating  the  individual 
patient,  may  in  the  aggregate  throw  much  light  upon  the  tuber- 


582  LABOKATORY   METHODS 

culosis  problem  as  a  whole;  these  results  are  about  all  that  may- 
be expected. 

Diagnostic  and  Prognostic  Value  of  Individual  Laboratory 
Findings. — The  weight  of  individual  findings  varies  somewhat 
with  respect  to  whether  or  not  bacilli  have  been  found  in  the 
sputum;  so,  in  the  following  discussion  individual  tests  will  be 
considered:  first,  as  found  in  the  prebacillary  stage  of  the  dis- 
ease; and  second,  as  found  with  bacilli  in  the  sputum,  after 
cavitation  has  taken  place.  For  the  most  part,  such  findings  are 
of  presumptive  evidence  only,  as  they  are  not  wholly  specific 
for  tuberculosis. 

Sputum. — The  nearest  specific  finding  is  a  high  lymphocyte 
content  in  the  sputum.  Fifty  per  cent  or  more  of  these  cells 
indicate  tuberculosis  in  probably  over  90  per  cent  of  cases,  al- 
though theoretically  a  number  of  other  lung  conditions  should 
give  the  same  picture.  As  yet,  however,  nothing  has  been  re- 
ported to  minimize  the  importance  of  this  finding  as  pointing 
to  tuberculosis.  The  later  development  of  bacilli  in  the  sputum 
of  some  of  these  patients  and  the  occurrence  of  the  same  picture 
in  old  healing  lesions,  is  convincing. 

The  albumin  reaction  is  less  reliable  as  it  is  present  wherever 
pus  is  found,  unless  it  has  been  previously  split  by  the  action 
of  ferments  and  bacteria  in  the  lung.  Such  loss  of  albumin  is 
found  in  conditions  favoring  retention  of  sputum,  such  as  lung 
abscess  and  some  cases  of  bronchiectasis.  Chronic  bronchitis 
gives  little  or  no  albumin  in  the  sputum;  acute  bronchitis  with 
high  pus  content  gives  a  considerable  reaction.  Any  albumin 
reaction  then,  persisting  over  a  period  of  time  longer  than  the 
course  of  acute  infections,  is  due  probably  to  tuberculosis.  Af- 
ter cavitation  has  occurred,  the  presence  of  albumin  is  constant 
until  healing  has  taken  place. 

Disappearance  of  Bacilli  Under  Treatment.— Of  special  im- 
portance to  the  patient  and  his  friends  is  the  permanent  disap- 
pearance of  bacilli  from  the  sputum,  during  the  course  of  treat- 
ment. The  more  extensive  the  involvement  the  more  difficult 
it  is  to  secure  this  result.  Also,  the  better  the  technic  employed 
in  searching  for  bacilli,  the  less  glittering  will  be  the  result. 
Rare  bacilli,  formerly  overlooked  by  our  cruder  methods,  are 


DISAPPEARANCE   OP  BACILLI  583 

found  today;  so  that  the  high  percentage  of  patients  positive  on 
entrance  but  losing  their  bacilli  under  treatment,  reported  in 
past  years,  does  not  hold  today.  In  1909  a  clinical  report  was 
published  including  all  patients  who  had  been  in  the  sanatorium 
for  at  least  3  months.  There  were  277  patients  who  had  bacilli 
on  entrance,  classified  as  i  Stage,  12;  n  Stage,  26;  and  in  Stage, 
239.  Of  these,  11  of  the  i  Stage,  or  91  per  cent;  16  of  the  n 
Stage,  or  61  per  cent;  and  17  of  the  m  Stage,  or  7.1  per  cent, 
lost  their  bacilli  during  treatment.  The  average  course  of 
treatment  was  6  months  for  the  i  Stage ;  8  months  for  the  n  Stage ; 
and  10  months  for  the  m  Stage. 

The  sputum  examinations  at  that  time  were  made  mostly  from 
morning  specimens,  partly  after  direct  smear  and  partly  after 
fermentation  of  the  specimen.  A  small  proportion  of  the  exam- 
inations were  made  from  twenty-four  hour  specimens  followed 
by  fermentation.  The  collection  of  twenty-four  hour  specimens 
was  started  in  July,  1907;  although  in  patients  with  bacilli,  morn- 
ing specimens  were  considered  sufficient.  Beginning  with  July 
17,  1911,  twenty-four  hour  specimens  were  collected  as  a  routine 
procedure,  and  the  three-day  specimen  was  adopted  for  all  pa- 
tients in  whose  sputum  bacilli  had  previously  been  negative  or 
rare.  Since  that  time,  in  a  total  of  5160  sputa  examined,  1150 
have  been  three-day  specimens. 

Table  XIII  is  a  summary  of  all  patients  who  were,  under 
treatment  for  at  least  3  months,  and  in  whose  sputum  bacilli 
were  found  at  least  once.  The  patients  are  arranged  in  two 
groups:  those  leaving  prior  to  July,  1911;  and  those  entering  after 
July,  1911. 

The  number  of  patients  in  the  i  and  n  Stages  above  are  too 
few  in  number  to  make  valid  comparisons;  but  in  Stage  in 
and  in  the  total  of  all  stages,  a  diminution  in  the  percentage 
of  patients  losing  their  bacilli,  during  the  course  of  treatment,  is 
noticed  when  the  better  technic  is  used.  The  percentage  is  re- 
duced from  8.4  per  cent  to  4.7  per  cent  for  Stage  in  cases,  and 
from  10.7  per  cent  to  8.5  per  cent  for  all  stages.  The  percentage 
of  those  negative  on  first  examination  but  developing  bacilli 
during  the  course  of  treatment  is  slightly  less  with  the  better 
technic,  due  probably  to  greater  effort  in  making  the  first  ex- 
amination successful.     While  the  percentage   of  patients  who 


584 


LABORATORY   METHODS 


TABLE  XIII. 


Showing  Reduction  of  the  Percentage  of  Patients  Losing  Their  Bacilli 
Under  Treatment,  When  Better  Technics  are  Employed 


Examinations  before  July  17th,  1911. 
Technic    employed.      Fresh    morning 
specimens  and  24  hr.  specimens  exam- 
ined by  direct  smear  and  after  fermen- 
tation.    Preparations  searched  for  5  to 
10  min.  before  reporting  negative. 

After  July  17th,  1911 
Technic  employed.    All  specimens  were 
24  hr.  or  3  day  quantities,  fermented 
and  shaken  in  the  mechanical  shaker. 
Preparations    searched    for    15     min. 
before  reporting  negative. 

TOTALS 

I 

STAGE 

II 

STAGE 

III    1 

STAGE 

ALL 

STAGES 

TOTALS 

I 

STAGE 

II 

STAGE 

III 

STAGE 

ALL 

STAGES 

Patients 

6 

19 

274 

299 

Patients 

7 

34 

254 

.295 

Examina- 
tions  

43 

91 

2414 

2558 

Examina- 
tions  

59 

157 

2522 

2738 

Average 
ex.  per 
patient. .  . 

7.2 

4.6 

8.9 

8.6 

Average 
ex.  per 
patient. .  . 

8.4 

4.6 

10 

9.3 

Patients 

losing 

bacilli 

3 

6 

23 

32 

Patients 

losing 

bacilli 

4 

9 

12 

25 

Loss 

per  cent.  . 

50 

31.6 

8.4 

10.7 

Loss 

per  cent.  . 

57.1 

26.5 

4.7 

8.5 

Patients 
gaining 
bacilli. . .  . 

0 

3 

10 

13 

Patients 
gaining 
bacilli. . .  . 

2 

0 

9 

11 

Gain 
per  cent.  . 

0 

15.9 

3.7 

4.3 

Gain 

per  cent.  . 

2.9 

0 

3.5 

8.7 

lose  their  bacilli  has  been  considerably  reduced,  the  percentage 
of  favorable  clinical  results  has  been  increased. 

From  these  facts  it  is  evident  that  the  chances  for  a  patient 
in  Stage  in  getting  rid  of  his  bacilli  during  the  average  period 
of  treatment — 9  months  in  the  above  series — is  very  small;  and 
if  still  more  sensitive  technics  were  employed — pig  inoculation 
or  Petroff's  cultural  method — the  chances  would  approximate 
zero.  These  cases  must  then  be  considered  as  possible  carriers 
for  a  long  period  of  time  after  treatment. 

Another  feature  in  the  comparison  of  the  two  technics  which 
does  not  appear  in  the  table,  is  the  higher  percentage  of 
patients  who  show  bacilli  intermittently  by  the  better  than  by 
the  poorer  technic.     There  were  eighty-four  intermittent  cases 


INTERPRETATION    OF   BLOOD   FINDINGS  585 

in  a  total  of  295,  or  29  per  cent  in  the  former;  and  69  in  a  total 
of  299,  or  23  per  cent  in  the  latter. 

Blood. — Blood  findings  offer  little  aid  to  diagnosis  in  the  pre- 
bacillary  stage,  except  in  comparatively  rare  instances  where 
cavitation  is  preceded  by  severe  constitutional  symptoms;  in 
such  cases  the  almost  specific  character  of  the  neutrophile  stip- 
pling has  enabled  me  to  differentiate  between  tuberculosis  and 
certain  other  non-tuberculous  conditions.  Rarely  one  meets  a 
case  of  miliary  tuberculosis  presenting  the  same  picture  clini- 
cally; the  presence  of  a  leucocyte  count  below  5000  speaks  for 
the  miliary  condition  with  a  grave  prognosis;  a  high  leucocyte 
count — 10,000  or  above,  depending  on  the  severity  of  symptoms, 
rather  indicates  approaching  cavitation,  without  prognostic  sig- 
nificance. Arneth's  variation  in  the  neutrophiles  is  entirely  non- 
specific, occurring  in  practically  all  infections  with  constitutional 
symptoms,  A  high  lymphocyte  count  was  formerly  looked  upon 
as  of  diagnostic  value,  but  so  many  other  conditions  produce 
the  same  picture  that  little  may  be  expected  of  it;  further,  the 
discovery  in  later  years  that  the  average  lymphocyte  percentage 
in  normal  persons  is  much  higher  than  was  originally  claimed  by 
Ehrlich  has  also  discounted  the  value  of  the  lymphocyte  per- 
centage. After  cavitation  has  taken  place,  however,  there  is  a 
close  parallel  between  the  number  of  lymphocytes  in  the  blood 
and  the  general  welfare  of  the  patient.  The  higher  the  count, 
the  better  on  the  average  is  the  condition  of  the  patient,  and  vice 
versa.  For  prognostic  purposes  a  count  of  500  or  below  indi- 
cates an  almost  certain  fatal  issue. 

Urine. — The  urine  findings  before  bacilli  appear  in  the  sputum 
are  of  little  value.  The  occurrence  of  a  diazo  and  urochromogen 
are  rare,  and  when  they  are  present  they  are  associated  with  the 
severe  constitutional  symptoms  accompanying  extensive  soften- 
ing or  a  miliary  condition.  These  two  conditions  might  at  times 
be  confused  with  typhoid  fever  accompanied  by  pulmonary  and 
pleuritic  symptoms.  As  the  diazo  is  likely  to  occur  in  all  these 
conditions,  it  is  of  no  value  in  differentiating,  but  it  is  of  some 
value  in  excluding  pneumonia  in  which  it  occurs  less  commonly. 
The  diazo  is  not  frequent  in  tuberculous  meningitis  unless  the 
condition  is  terminal  to  massive  pulmonary  involvement,  so  that 


586  LABORATORY    METHODS 

it  should  be  of  some  weight  in  differentiating  tuberculous  menin- 
gitis from  typhoid  fever,  miliary  tuberculosis  and  massive  pul- 
monary involvement,  when  mental  confusion  is  present. 

The  diazo  is  of  limited  prognostic  value.  An  occasional  oc- 
currence indicates  nothing  more  than  that  the  disease  is  quite 
active  at  the  time  of  examination.  Continued  occurrence  of  the 
reaction  gives  a  grave  prognosis.  Two  patients  in  whom  I  found 
a  positive  test  at  y5  dilution  of  the  urine,  during  cavitation, 
never  gave  a  diazo  thereafter,  and  obtained  complete  arrestment. 
Both  are  alive  and  well,  one  after  6  years,  the  other  after  2 
years;  on  the  other  hand,  a  diazo  of  such  intensity  persisting 
for  one  month  is  almost  certainly  fatal  within  a  few  months' 
time. 

Indican  findings,  considered  alone,  are  of  uncertain  value  in 
the  individual  case,  although  an  increased  indican  elimination 
has  long  been  known  to  accompany  tuberculosis.  There  is  con- 
siderable variation  in  the  amount  of  indican  eliminated  in  twenty- 
four  hours,  so  that  little  information  is  likely  to  be  obtained  from 
a  single  examination.  Some  years  ago  I  determined  the  amount 
of  indican  in  three  successive  daily  twenty-four  hour  urines  from 
45  different  patients.  Comparing  the  results  for  the  three  days 
it  was  found  that  in  6  patients  the  highest  reading  was  less 
than  25  per  cent  greater  than  the  lowest;  in  3,  33%  per  cent; 
in  11,  50  per  cent;  in  16,  100  per  cent,  and  in  9  more  than  100 
per  cent.  In  interpreting  indican  findings,  one  must  know 
whether  or  not  a  cathartic  was  given  before  or  during  the  time 
the  specimen  was  being  saved;  and  also  as  to  the  result  of  the 
cathartic.  Should  one  find  a  persistent  increase  of  indican  in  a 
patient  with  bowel  symptoms,  tuberculous  enteritis  should  be 
thought  of;  these  patients  almost  invariably  have  indican  values 
above  30  (15  being  normal;  see  Indican  determination,  p.  574) 
even  though  on  a  restricted  proteid  diet. 

The  chief  value  of  indican  determinations  has  been  as  an  aid 
in  the  regulation  of  the  diet  of  the  institution  as  a  whole,  as 
well  as  the  diet  of  individual  patients.  In  1908,  a  study  was 
made  of  indican  reports  made  up  to  that  time;  the  first  examina- 
tion on  entrance  was  compared  with  the  average  of  all  succeed- 
ing examinations  from  each  patient.    It  was  found  that  the  aver- 


INTERPRETATION   OF  INDICAN  FINDINGS  587 

age  increase  of  indiean  in  69  patients  was  from  15  to  26,  while 
the  average  decrease  in  32  patients  was  from  26  to  14.  The  pa- 
tients were  then  classified  with  reference  to  their  general  condi- 
tion and  habits  of  eating.  It  was  found  that  those  whose  indiean 
increased  markedly  on  our  diet  were  almost  invariably  the  ambula- 
tory patients  who  were  trying  to  carry  out  faithfully  the  er- 
roneous teaching  of  "stuffing."  The  practice  had  been  discarded 
several  years  before  in  the  institution,  but  it  could  hardly  be 
expected  to  die  quickly  after  having  been  advanced  and  main- 
tained with  such  insistence  by  the  profession.  In  many  cases 
patients  were  told  by  the  physician  referring  them  that  what 
they  needed  was  good,  nutritious  food  in  excess  of  what  their 
appetites  called  for.  It  was  not  an  easy  task  to  break  up  a 
habit  which  had  such  a  strong  reason  for  its  existence.  How- 
ever, the  high  indicanuria  in  at  least  two-thirds  of  the  patients 
was  so  clearly  dependent  upon  the  excess  of  proteid  food  in- 
gested, that  effort  was  made  to  break  up  the  habit.  After  a 
course  of  general  lectures,  with  a  careful  watch  over  individual 
cases,  the  indiean  determinations  were  compared  as  above  from 
the  next  76  patients  entering,  with  the  result  that  only  23  pa- 
tients showed  an  increase  of  from  22.1  to  27.4,  while  53  showed 
a  decrease  of  27.3  to  14.0.  These  averages  are  made  occasionally, 
whenever  there  is  reason  to  believe  that  the  patients  have  for- 
gotten the  previous  lesson. 

The  following  chart  shows  a  curve  made  from  the  averages 
of  all  indiean  values  found  for  each  month  for  seven  years.  The 
technic  has  been  uniform  throughout.  From  60  to  80  examina- 
tions are  averaged  each  month,  so  that  the  chart  represents  the 
findings  in  about  5500  twenty-four  hour  urines.  (See  Fig. 
102.) 

On  an  average  the  curves  show  a  lower  indiean  elimination 
since  1912.  It  was  before  that  time  that  we  experienced  most  of 
our  trouble  from  overeating.  Aside  from  this  tendency,  there 
are  certain  other  causes  tending  to  influence  the  indiean  curve. 
In  April,  1912,  a  sharp  rise  in  the  curve  followed  a  period  of 
warm  days  entirely  out  of  season.  The  remaining  months  of  the 
year  were  cool.  After  a  cool  spring  and  summer  in  1916,  a 
period   of  two  weeks   of  warm  weather  were   experienced  in 


588 


LABORATORY   METHODS 


August,  with  a  rise  in  the  curve.  This  rise  in  the  indican  curve, 
with  the  usual  train  of  minor  symptoms,  is  the  same  condition 
met  in  the  eastern  states  with  the  approach  of  the  warmer  spring 
months.  With  us  it  is  likely  to  occur  at  any  time,  due  to  our 
lack  of  well  denned  seasons.  Just  what  atmospheric  conditions 
are  responsible  for  this  rise  in  the  curve  is  not  clear.  It  is  not 
the  temperature  alone;  for  low  indican  values  are  often  found 
in  hot  weather.  It  may  be  due  largely  to  the  effect  which  cer- 
tain atmospheric  conditions  have  in  increasing  bacterial  activity, 
rendering  food  less  digestible,  disturbing  the  digestion  of  the 
patients  and  increasing  intestinal  intoxication. 


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Fig.  102. — Institutional  indican  curve  determined  from  the  average  of  all  indican  findings 

for  the  month. 


Whatever  the  exact  explanation,  the  curve  is  of  much  value 
in  guiding  our  patients  through  these  periods  of  disturbance. 
They  are  advised  to  diminish  the  proteid  content  of  their  diet. 

Tubercle  bacilli  in  urine,  whether  from  the  kidney  or  else- 
where in  the  urinary  tract,  give  a  grave  prognosis;  although 
cases  have  been  reported  as  having  healed.  Bacilli  have  been 
reported  as  having  been  found  in  the  urine  in  miliary  tuber- 
culosis, without  involvement  of  the  urinary  tract;  but  as  such 
cases  are  rare,  confusion  is  not  likely  to  result.  The  presence 
of  pus  with  bacilli  in  the  urine  justifies  the  opinion  that  tuber- 
culosis exists  somewhere  in  the  tract. 


CORRELATION   OF  LABORATORY  FINDINGS  589 

Feces. — The  diagnosis  of  tuberculosis  of  the  bowel  from  the 
presence  of  tubercle  bacilli  alone  in  the  feces  should  not  be 
made;  even  though  they  are  continuously  present.  In  case  bowel 
symptoms  are  present,  the  condition  should  be  thought  of;  but 
the  diagnosis  can  by  no  means  be  established  for  a  certainty. 
The  continuous  presence  of  occult  blood  in  a  patient  with  ad- 
vanced pulmonary  tuberculosis,  provided  ulcer  of  stomach  or 
duodenum  can  be  excluded,  rather  points  strongly  to  tubercu- 
lous enteritis,  if  clinical  symptoms  are  also  present.  This  com- 
plication is  rarely  recognized  until  the  disease  is  far  advanced. 

Correlation  of  Laboratory  Findings. — In  the  proper  correla- 
tion of  findings  from  all  sources,  is  to  be  found  the  chief  value 
of  laboratory  work;  in  such  a  method  negative  findings  by  in- 
dividual tests  are  often  as  important  as  are  the  positive  findings 
obtained  by  other  tests;  the  varying  pathological  condition 
of  the  patient  causes  a  corresponding  change  in  the  laboratory 
findings;  so  that  negative  findings  often  enable  the  clinician  to 
exclude  certain  disease  processes  from  consideration  in  diagno- 
sis, while  positive  findings  give  him  an  idea  of  the  nature  and 
extent  of  the  condition  itself. 

When  the  constitutional  symptoms  are  slight,  the  laboratory 
findings  vary  little  from  normal;  but  when  they  are  pronounced, 
whether  bacilli  appear  in  the  sputum  or  not,  we  must  differ- 
entiate between  tuberculosis  and  other  respiratory  infections. 
Even  though  we  are  positive  that  the  clinical  picture  is  one  of 
uncomplicated  tuberculosis,  the  assembling  of  the  laboratory 
facts  gives  a  more  accurate  idea  of  the  condition  of  the  pa- 
tient. In  the  sanatorium  it  is  rarely  necessary  to  differentiate 
tuberculosis  from  the  acute  respiratory  infections  on  entrance; 
as  95  per  cent  of  all  entrants  have  been  under  the  care  of  their 
physicians  for  sufficient  time  to  exclude  almost  entirely  the  lat- 
ter diseases.  The  following  case  was  an  exception  to  this  rule, 
as  the  patient  was  delirious  and  his  family  were  unable  to  give  a 
satisfactory  history;  they  rather  attributed  his  mental  state  to 
business  worries. 

On  entrance  the  patient  was  delirious;  temperature  104.4, 
pulse  124.  Physical  examination  in  recumbent  position  was  un- 
satisfactory,   giving    weak    breath    sounds     over    right    apex. 


590  LABORATORY   METHODS 

Sputum:  small  amount;  purulent  in  character;  no  bacilli  pres- 
ent. Urine:  24  hr.  1000  c.c;  albumin,  large  trace;  diazo  at  % 
dilution.  Blood:  white  cells  4780;  neutrophiles  74  per  cent; 
lymphocytes  24  per  cent;  neutrophile  stippling,  moderate.  It 
was  observed  at  the  time  that  the  stippling  was  unlike  what 
I  had  found  in  severe  toxemias  in  uncomplicated  tuberculosis 
and  a  note  was  made  of  the  differences.  The  granules  were 
neither  as  distinct  nor  as  black  in  color,  as  is  invariably  found 
in  the  latter.    Bacilli  were  not  present  in  the  feces. 

The  clinical  picture  presents  these  possibilities:  tuberculous 
meningitis;  miliary  tuberculosis;  massive  pulmonary  tubercu- 
losis; some  acute  respiratory  infection,  as  pneumonia  or  influenza; 
typhoid  fever  with  pulmonary  complication;  and  finally,  any  of 
the  infectious  diseases  with  pulmonary  complications  in  a  per- 
son who  was  previously  mentally  deranged.  The  marked  diazo 
reaction  with  leucopenia  almost  certainly  limits  the  possibilities 
to  miliary  tuberculosis,  massive  pulmonary  tuberculosis,  and  ty- 
phoid fever;  but  the  physical  examination,  though  unsatisfactory, 
almost  certainly  excluded  pulmonary  tuberculosis  of  such  de- 
gree as  would  be  necessary  to  produce  such  toxemia.  The  dif- 
ferentiation of  miliary  tuberculosis  and  typhoid  fever  was  made 
in  favor  of  the  latter,  on  the  character  of  the  neutrophile  stip- 
pling, as  not  due  to  the  toxemia  of  tuberculosis.  Two  days  later 
rose  spots  appeared  on  the  abdomen.  Repetition  of  the  labora- 
tory tests  5  days  later  gave  a  diazo  at  only  %  dilution;  white 
cells  4050,  bacilli  negative.  The  blood  culture  for  typhoid 
bacilli  was  not  made.  Sputum  and  urine  were  examined  later 
3  different  times,  with  the  result  that  bacilli  were  never  found 
and  the  diazo  was  absent  at  the  end  of  three  weeks.  The  sub- 
sequent history  showed  that  we  were  dealing  with  typhoid  fever. 
The  temperature  remained  between  104°  and  105°  for  13  days, 
coming  gradually  to  normal  on  the  21st  day,  and  remaining 
normal  thereafter  for  four  weeks,  except  for  an  occasional  rise 
to  100°.  In  this  case  the  most  specific  finding  was  the  character 
of  the  neutrophile  stippling,  which  is  suggested  for  the  use  of 
those  workers  who  have  more  opportunity  for  differentiating 
these  cases  than  I  have  had. 

In  the  following  case,  I  believe  the  laboratory  findings  were 


CORRELATION   OF  LABORATORY   FINDINGS  591 

important  not  only  in  confirming  the  physical  findings,  but  in 
indicating  a  more  accurate  prognosis  than  would  be  ventured 
from  the  former.  There  was  no  question  of  the  diagnosis  of 
tuberculosis,  although  bacilli  had  never  been  found.  The  patient 
gave  a  history  of  cough  at  times  with  or  without  sputum.  Six 
weeks  before  entering  the  institution  he  had  a  "cold"  lasting 
for  three  weeks,  with  a  maximum  temperature  of  102°  to  104°, 
and  subnormal  in  the  morning.  Physical  examination  showed 
extensive  infiltration  in  both  lungs.  The  temperature  on  en- 
trance was  99°;  pulse  90.  Sputum,  24  hour  specimen,  gave  no 
bacilli.  Urine,  no  diazo.  Blood,  white  cells,  3850.  Because  of 
the  leucopenia,  the  white  cell  count  was  repeated  the  next  day, 
giving  3900.  Three  days  later  it  was  5700;  lymphocytes  910; 
Arneth's  index  97.  Three  days  later,  the  count  was  3500;  a 
diazo  at  V2  dilution  was  found  in  the  urine;  and  a  3  day  sputum 
was  negative  for  bacilli.  At  this  point  the  temperature  was  102° 
without  morning  remission,  continuing  in  this  manner  until 
death  10  weeks  later.  Laboratory  examinations  were  repeated 
8  days  after  the  last  examinations.  The  white  cell  count  was 
4050;  diazo  %;  tubercle  bacilli  25  per  field.  The  white  cell 
count  repeated  10  days  later  was  4700,  and  8  days  after  that, 
6050.  Seven  weeks  after  entrance  the  urine  gave  a  diazo  of  y12; 
the  sputum  75  bacilli  per  field. 

The  main  point  of  interest  in  this  case  is  the  persistent  leuco- 
penia, associated  with  the  increasing  intensity  of  the  diazo,  which 
justified  the  opinion  of  an  early  fatal  issue,  which  was  not  in- 
dicated by  the  history  and  physical  findings.  The  second  com- 
plete physical  examination,  made  one  month  after  entrance, 
showed  that  areas  of  infiltration  had  increased  markedly.  This 
was  a  case  of  miliary  tuberculosis  of  the  lung. 

Since  developing  the  special  technics  for  the  determina- 
tion of  the  sediment  volume  and  the  length  index  of  tubercle 
bacilli,  I  have  found  the  findings  very  valuable  in  explaining 
the  nature  of  the  lesser  changes  taking  place  in  the  patient's 
condition  from  day  to  day.  Those  who  are  engaged  in  following 
the  course  of  the  disease  in  tuberculous  individuals,  know  of 
the  vast  number  of  little  complaints  of  such  patients,  such  as 
V2  to  1  degree  rise  in  temperature  without  evident  cause;  the 


592  LABORATORY   METHODS 

tendency  to  tire  easier  on  certain  days  as  compared  with  others; 
loss  of  appetite,  etc.  These  complaints  come  from  those  who  are 
comparatively  well,  as  well  as  from  those  who  have  considerable 
involvement  with  constitutional  symptoms. 

There  has  been  some  speculation  concerning  the  meaning  to 
be  attached  to  the  relative  length  of  bacilli  found  in  sputum; 
the  two  important  opinions  being:  first,  that  the  short  uniformly 
stained  forms  are  of  the  bovine  type,  while  the  long  and  beaded 
forms  are  of  the  human  type;  and  second,  that  the  short  and 
long  forms  are  the  younger  and  older  bacilli  respectively.  Al- 
though I  have  kept  routine  records  of  the  estimated  relative 
length  of  bacilli  for  eight  years,  I  came  to  the  conclusion  that 
it  was  practically  impossible  to  form  an  idea  of  the  relative 
length  of  bacilli,  without  some  scheme  for  measurement.  Since 
perfecting  such  a  device,  I  have  been  able  to  classify  bacilli  to 
within  a  narrow  margin  of  error.  I  find  that  many  of  the  com- 
plaints referred  to  above  are  associated  with  the  softening  of 
minute  areas  in  the  lung,  as  is  shown  by  the  increase  of  the  short 
bacilli.  We  have  in  this  method  a  means  of  detecting  these 
slight  changes,  which  neither  the  stethoscope  nor  other  means, 
of  which  I  know,  can  determine.  Such  information  is  of  great 
value  in  individual  cases,  such  as  those  showing  very  irregu- 
lar temperature  curve,  and  in  which  there  is  doubt  as  to  whether 
the  temperature  is  referable  to  the  lung  involvement,  to  some 
tuberculous  complication,  or  to  some  non-tuberculous  process. 

To  rely  on  the  patient's  statement  that  he  is  coughing  and 
raising  more  today  than  he  did  yesterday  or  last  week  often 
leads  the  clinician  to  wrong  conclusions.  Changes  in  atmospheric 
conditions  may  produce  those  symptoms,  and  may  even  produce 
a  slight  rise  in  temperature.  Further,  worry,  fright,  anger  or 
other  emotion  may  either  directly  or  indirectly  affect  the  tem- 
perature curve,  producing  a  train  of  symptoms  besides  the  ones 
mentioned.  The  differential  diagnosis  in  these  cases  has  re- 
peatedly been  made  to  the  satisfaction  of  the  clinicians  and  the 
patient  himself  by  means  of  the  sputum  findings  as  illustrated 
in  the  charts.     (See  Figs.  103  and  104.) 

In  addition  to  the  temperature  curve  the  charts  present  5 
curves  made  from  quantitative  observations  extending  over  sev- 


CORRELATION   OP  LABORATORY  FINDINGS 


593 


eral  months.  The  temperature  curve  was  made  from  the  aver- 
ages of  the  highest  temperature  for  the  day,  of  three  successive 
days.  This  method  minimizes  the  influence  which  various  out- 
side factors  would  have  on  the  curve.    For  instance,  indigestion 


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Fig.  103. — Chart  showing  correlation  of  sputum  findings  and  their  relation  to  tem- 
perature curve.  A,  Albumin  curve;  B,  total  24  hour  sputum;  C,  number  of  bacilli; 
D,  length  index;  E,  sediment  volume. 


and  the  various  emotions,  may  cause  a  rise  for  a  single  day  of 
one  or  two  degrees,  but  when  averaged  with  two  days  of  usual 
temperature,  it  would  not  appear  of  much  importance  on  the 
chart. 

Fig.   103   presents  the  findings    in    a    female    patient    whose 


594 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 


lung  involvement  has  extended  under  treatment.  It  will  be 
noticed  that  in  general  the  albumin,  total  quantity  of  sputum, 
relative  number  of  bacilli,  and  sediment  curves  are  in  agreement 
with  the  temperature  curve.  The  length  index  curve  bears  an 
inverse  relation  to  the  other  curves;  that  is  the  greater  the  activ- 
ity the  shorter  the  bacilli,  and  the  lower  the  index.     This  rela- 


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Fig.  104. — Chart  showing  correlation  of  sputum  findings  and  their  relation  to  tem- 
perature curve.  A.  Albumin  curve;  B.  total  24  hour  sputum;  C,  number  of  bacilli; 
D,  length  index;  E,  sediment  volume. 


tionship  is  shown  in  Fig.  104  and  in  some  40  other  charts,  which  I 
have  made  from  other  patients,  establishing  beyond  all  doubt 
the  meaning  of  short  bacilli,  and  confirming  the  opinion  of  others 
who  have  expressed  this  view.  This  view  does  not  necessarily 
weigh  against  the  other  opinion  that  short  bacilli  represent  one 
type  and  long  bacilli  another  type.    The  greatest  fluctuation  in 


CORRELATION   OF  LABORATORY   FINDINGS  595 

index  which  I  have  met  in  any  single  patient  was  from  264  on 
entrance  to  204  after  cavitation  two  months  later.  Another 
patient  on  entrance  gave  an  index  of  177,  and  after  two  months 
of  unusual  progress,  an  index  of  218  was  found.  Some  of  these 
patients  have  been  under  observation  for  10  to  15  months,  and 
while  the  index  varies  considerably,  it  does  so  within  fairly 
narrow  limits — 50  to  40  points  in  index — which  is  not  great 
considering  the  possible  range  from  127  to  264  as  found  in  my 
work.  This  rather  points  strongly  to  a  number  of  different 
types  of  organisms. 

I  have  not  been  able  to  find  any  special  significance  in  the  al- 
bumin curve,  and  the  total  24  hour  specimen  varies  so  greatly 
that  its  curve  is  of  little  value  in  studying  these  finer  points 
in  diagnosis;  so  that  in  practice,  the  sediment  volume,  length 
index,  and  relative  number  of  bacilli  are  given  most  weight. 


CHAPTER  XXI. 

TEE   DIAGNOSIS   AND   DIFFERENTIAL   DIAGNOSIS 

OF     TUBERCULOSIS,     PARTICULARLY 

PULMONARY  TUBERCULOSIS. 

The  diagnosis  of  tuberculosis  is  so  intimately  associated  with, 
its  differentiation  from  other  conditions  that  it  seems  logical 
and  best  to  discuss  these  subjects  together. 

The  Importance  of  Diagnosis  in  Hidden  Tuberculosis. — AVhile 
our  chief  duty  as  clinicians,  as  yet,  so  far  as  tuberculosis  is  con- 
cerned, is  to  diagnose  the  disease  as  it  affects  the  lungs,  yet  we 
must  not  lose  sight  of  the  fact  that  it  may  affect  any  tissue  or 
organ  of  the  body;  and  that  each  lesion  may  produce  the  same 
group  of  toxic  symptoms  together  with  a  group  which  will  be 
characteristic  of  the  particular  tissue  or  organ  affected.  It  is 
especially  necessary  to  bear  this  in  mind  if  we  would  understand 
the  indefinite  group  of  toxic  symptoms  which  accompany  a 
partially  quiescent  focus  in  the  peribronchial  or  tracheal  glands 
where  the  main  complaint  of  the  patient  is  that  which  might  be 
caused  by  any  slight  toxemia.  In  such  cases  we  have  the  picture 
of  loss  of  tone  and  lack  of  nervous  and  physical  force  without 
any  apparent  cause.  In  malarial  districts  malaria  is  usually 
diagnosed,  while,  in  other  places  neurasthenia,  overwork,  or  a 
general  rundown  condition  is  supposed  to  be  the  cause. 

As  clinicians  we  are  apt  to  forget  the  possibility  of  such  symp- 
toms being  caused  by  hidden  foci;  and,  failing  to  find  tubercu- 
losis in  the  lung,  declare  that  it  does  not  exist.  We  should  never 
lose  sight  of  the  fact  that,  with  clinical  symptoms  belonging  to 
the  toxic  group  suspicious  of  tuberculosis,  and  an  inability,  by 
most  painstaking  examination,  to  find  either  a  tuberculosis  or 
other  cause  for  the  same,  we  have  not  ruled  out  the  possibility  of 
a  hidden  tuberculous  focus.  The  pulmonary  tissue  is  not  the 
only  part  attacked  by  this  infection;  in  fact,  the  peribronchial 
and  peritracheal  glands  are  nearly  always  infected  prior  to  the 


DIFFICULTIES   OF  DIAGNOSIS  597 

pulmonary  involvement  and  symptoms  can  arise  from  the  escape 
of  toxins  from  these  glandular  foci,  even  although  the  glands 
may  not  be  enlarged  sufficiently  to  cause  symptoms  other  than 
those  of  a  toxic  nature,  and  even  though  they  cannot  be  out- 
lined on  physical  examination.  It  is  equally  important  to  remem- 
ber that,  given  a  lesion  in  some  organ  other  than  the  lung 
which  is  suspected  of  being  tuberculous,  with  undeniable  evi- 
dence of  tuberculosis  being  present  in  the  body  of  the  patient, 
such  as  a  positive  tuberculin  reaction;  or,  a  positive  sputum 
finding,  this  positive  evidence  does  not  prove  the  tuberculous 
etiology  of  the  process  in  question. 

Difficulties  of  Diagnosis. — The  difficulties  which  attend  the 
diagnosis  of  tuberculosis  come  from  many  sides.  The  fact  that 
tuberculosis  has  been  a  fatal  disease  for  so  many  centuries  still 
militates  against  its  detection.  Although  tuberculosis  if  diag- 
nosed early  and  treated  intelligently  has  been  removed  from 
the  list  of  fatal  diseases,  yet  this  is  only  accepted  in  a  half- 
hearted manner.  It  is  not  fully  believed  by  either  the  lay- 
men or  the  profession.  This  lack  of  faith  in  its  curability  adds 
to  its  deadliness  because  it  keeps  up  such  a  fear  of  the  disease 
that  the  patient  and  his  friends  fight  against  knowing  the  truth, 
and  medical  men  shrink  from  finding  it  out,  or,  if  they  know  it, 
from  telling  the  patient  until  the  early  curable  disease  has  be- 
come an  advanced  hopeless  one.  This  can  only  be  remedied  by 
medical  men  accepting  what  intelligent  treatment  can  do  for 
truly  early  tuberculosis  and  appreciating  the  great  danger  of 
delay;  and  then  proclaiming  it  far  and  wide  until  the  truth  is 
fully  known. 

It  requires  Herculean  effort  to  work  against  the  tide  of  uni- 
versal public  opinion;  yet,  this  is  the  task  imposed  upon  those 
who  are  striving  for  early  diagnosis  and  cure  of  tuberculosis. 

The  insidiousness  of  tuberculosis  is  also  a  factor  which  makes 
the  real  diagnosis  difficult.  If  symptoms  came  on  at  once  after 
infection  took  place,  it  would  be  comparatively  an  easy  matter 
to  make  an  early  diagnosis,  but  such  is  not  the  case.  Infection 
in  tuberculosis  takes  place  weeks,  months,  or  years  before  clini- 
cal symptoms  are  recognized,  the  lesion  having  gone  through  a 
succession  of  changes  from  quiescence  to  activity  and  extension. 


598  DIAGNOSIS   AND   DIFFERENTIAL  DIAGNOSIS 

This  goes  on  until  the  process  is  sufficiently  extensive  or  un- 
til the  activity  is  sufficiently  great  to  produce  symptoms  which 
are  unmistakable.  It  is  not  the  frank,  unmistakable  symptoms 
which  we  should  look  for.  These  are  evidence  of  advanced  dis- 
ease. We  should  always,  bearing  in  mind  the  frequency  and  in- 
sidiousness  of  this  disease,  be  on  the  alert  and  learn  to  recognize 
the  earliest  symptoms  which  occur. 

If  only  there  was  some  group  of  symptoms  which  is  pathog- 
nomonic or  some  specific  tests  which  are  infallible  in  their  diag- 
nosis of  early  tuberculosis  the  problem  could  be  minimized.  But 
there  is  not;  so  we  are  often  obliged  to  make  a  diagnosis  by 
exclusion  rather  than  by  positive  data. 

The  symptoms  of  early  tuberculosis  differ  according  to  the 
nature  and  location  of  the  lesion.  Toxins  produce  many  of 
them;  but  the  lesion  must  be  of  some  extent  before  these  are 
present  in  sufficient  amount  to  be  evident;  and  in  some  loca- 
tions the  symptoms  caused  by  the  inflammatory  process  are  more 
marked.  In  such  locations  as  the  meninges,  bones,  joints  and 
pleura,  symptoms  dependent  upon  toxemia  are  comparatively 
unimportant  at  first;  so  are  they  often  in  glandular  tubercu- 
losis, and  even  in  the  early  pulmonary  form.  On  the  other  hand, 
if  the  disease  is  located  in  the  tissues  where  it  can  run  a 
chronic  course,  sooner  or  later  the  toxic  group  of  symptoms  be- 
comes important.  In  marked  glandular  tuberculosis  and  in  pul- 
monary tuberculosis,  beginning  with  the  so-called  early  lesions, 
which  are  in  reality  lesions  which  are  more  or  less  extensive, 
toxemia  is  usually  accountable  for  a  definite  group  of  symptoms 
which  must  be  considered  in  the  diagnosis;  but,  unfortunately, 
these  are  not  constant. 

In  genuinely  early  lesions  there  is  no  definite  known  blood 
picture;  there  are  no  secretions  to  analyze;  and  the  specific  re- 
action of  the  body  cells  and  tissues  to  the  products  made  from 
the  tubercle  bacillus  (tuberculin)  is  usually,  though  I  believe 
wrongly,  considered  as  being  of  no  value  except  in  the  first  few 
years  of  life.  The  x-ray  can  give  evidence,  which,  if  rightly 
interpreted,  may  be  of  value  in  early  infections  located  in  some 
tissues,  particularly  the  joints  and  bones,  and  at  times  plates 
made  by  the  best  apparatus  with  expert  operators  will  greatly 


DIAGNOSTIC   IMPORTANCE   OP  TUBERCULIN   TESTS  599 

aid   in  the   diagnosis   of  lesions  in   early   pulmonary   invasions. 

The  Importance  of  the  Tuberculin  Tests  in  Diagnosis.— The 
function  of  the  tuberculin  tests  in  diagnosis  is  not  understood 
because  there  are  so  many  things  about  the  specific  reaction  be- 
tween tuberculin  and  the  sensitized  body  cells  that  we  do  not 
know.  However,  it  is  true  that  we  are  arriving  at  some  definite 
opinions.  Our  judgment  of  them,  now  that  we  know  the  fre- 
quency of  tuberculosis  in  early  years  and  understand  its  tend- 
ency to  go  through  cycles  of  activity  and  quiescence  over  a  long 
period  of  time  until  it  either  heals  or  produces  frank  clinical 
tuberculosis,  should  help  us  in  at  least  having  respect  for  a 
reaction  when  found,  even  if  it  does  not  afford  us  the  help  that 
we  desire  at  the  time. 

What  clinician  can  say,  by  the  most  careful  minute  examina- 
tion that  a  hidden  focus  of  tuberculosis  is  not  present  in  some 
portion  of  the  patient's  anatomy?  Yet  it  is  an  every  day  oc- 
currence for  physicians  to  make  such  statements  and  put  up  such 
opinions  against  positive  tnberculin  reactions.  They  do  not 
presume  to  do  so  in  syphilis.  If  a  positive  Wassermann  is  found, 
the  clinician  accepts  the  diagnosis  whether  he  is  able  to  find  a 
trace  of  trouble  clinically  or  not;  yet,  he  is  no  surer  in  this 
case  than  he  is  in  the  case  of  the  tuberculous  patient.  The 
answer  to  this  is  that  the  tuberculin  reaction  is  not  absolute, 
but  the  Wassermann  is.  How  has  this  been  proved?  Is  not  a 
hidden  active  tuberculous  focus  as  dangerous  as  a  hidden  active 
syphilitic  focus,  and  is  not  a  hidden  active  tuberculous  focus 
as  dangerous  as  a  detected  one?  Have  we  any  grounds  for 
belittling  the  danger  of  such  a  focus?  The  fact  that  all  such 
foci  do  not  become  serious  clinical  entities  and  do  not  go  on 
to  the  death  of  the  individual,  is  not  sufficient,  and  would  not 
be  accepted  in  any  other  field  of  medicine.  The  fact  that  tuber- 
culosis infects  probably  two-thirds  of  all  who  reach  adoles- 
cence; and  that  it  produces  toxins  which  impair  the  health  of  a 
considerable  per  cent  of  those  infected;  and  that  it  is  the  cause  of 
death  in  about  one-tenth  of  the  world's  population;  and  that  it 
causes  a  morbidity  four  times  as  great  as  its  mortality,  should 
be  sufficient  to  emphasize  the  importance  of  all  such  foci. 

If  only  we  could  determine  in  some  manner  how  long  specific 


600  DIAGNOSIS   AND  DIFFERENTIAL  DIAGNOSIS 

cell  stimulation  or  sensitization  remains  after  inoculation,  or 
particularly  after  healing  of  a  tuberculous  focus,  then  we  could 
arrive  at  some  definite  opinion  as  to  the  value  of  tuberculin  in 
diagnosis.  Until  such  time,  however,  we  are  obliged  to  make 
our  medical  imagination,  which  when  interpreted,  means  our 
ability  to  theorize  and  make  clinical  application  of  our  theories, 
take  the  place  of  definite  scientific  facts.  From  many  years  of 
observation  in  the  employment  of  the  tuberculin  tests,  particu- 
larly in  cases  of  pulmonary  tuberculosis,  the  writer  has  de- 
veloped a  firm  belief  in  the  value  of  these  tests.  If  only  we 
bear  in  mind  that  the  reaction  is  an  expression  of  specific  cellu- 
lar defense  against  (cell  sensitization)  the  bacillus  and  its 
specific  products,  we  will  understand  the  interpretation  of  the 
phenomena  better.  The  von  Pirquet  or  cutaneous  test  is  the 
one  that  I  prefer  to  use  and  the  one  which  I  think  is  easiest 
of  interpretation. 

It  is  thoroughly  established,  according  to  the  observations 
made  in  the  study  of  immunity,  that  an  individual  fights  infec- 
tion by  creating  a  specific  cell  defense.  This  specific  defense  is, 
to  a  certain  extent,  commensurate  with  the  severity  of  the  in- 
oculation and  the  reactive  capacity  of  the  body  cells,  which  lat- 
ter is  bound  up  quite  closely,  as  far  as  we  are  able  to  determine, 
with  the  degree  of  health  of  the  individual.  All  else  being  equal, 
the  strong  robust  patient  reacts  best  and  the  reaction  is  great- 
est when  the  infection  is  not  too  severe. 

If  these  observations  are  correct,  barring  the  very  severe  inocu- 
lations, we  should  expect  most  active  defense  when  there  is  the 
greatest  need,  that  is,  when  fighting  an  active  infection;  and 
the  greater  defense,  the  more  resistant  the  individual.  We  would 
also  expect  this  defense  to  show  as  an  increased  sensitization 
(an  increased  specific  defensive  power)  of  the  cells  toward  the 
bacillus  or  its  products.  Tuberculin,  containing  the  specific 
bacillary  products,  should,  then,  when  brought  in  contact  with 
the  body  cells,  provoke  a  reaction  commensurate  with  the  de- 
gree of  specific  sensitization  (specific  defensive  powers)  present, 
being  greater  when  the  patient's  reacting  power  is  good  and 
when  fighting  an  active  lesion,  and  less  marked  when  the  lesion 


VARIABILITY   OF   TUBERCULINS  601 

is  quiescent,  and,  theoretically,  at  least,  finally  disappearing  af- 
ter healing  has  occurred. 

This  has  been  my  experience  in  practice.  By  interpreting 
frank  prompt  reactions  as  positive  evidence  of  an  active  tuber- 
culous focus  somewhere  in  the  body,  one  will  not  go  far  wrong. 
Such  interpretation  will  not  be  farther  from  the  truth  than  our 
usually  accepted  methods  in  other  lines. 

This  leaves  a  very  important  class  of  cases  in  doubt,  however ; 
for  there  are  individuals  whose  body  cells  fail  to  react  properly 
in  building  up  specific  defense.  In  these,  accurate  diagnosis  and 
proper  therapeutic  measures  are  even  more  important  than  in 
those  whose  defense  is  good,  but  the  tuberculin  test  may  prove 
valueless.  This  will  be  in  a  smaller  proportion  of  cases  than  is 
generally  believed.  The  cachectic,  those  severely  ill,  those  with 
atrophied  skin  and  those  suffering  from  acute  illness  other  than 
tuberculosis,  particularly  some  of  the  acute  infectious  diseases, 
will  remain  in  doubt.  But,  knowing  this,  why  not  use  the  test 
for  the  definite  knowledge  it  gives.  Every  practitioner  of 
medicine  has  certain  limitations  in  diagnostic  and  therapeutic 
ability,  but  he  does  not  refuse  to  examine  and  treat  all  diseases 
because  of  it.     He  secures  other  help  to  cover  his  weakness. 

Let  it  be  understood  that  the  power  of  bacillary  products  (tu- 
berculin) to  seek  out  and  stimulate  specifically  sensitized  cells 
may  be  far  more  accurate  than  our  power  to  locate  and  deter- 
mine the  activity  or  quiescence  of  tuberculous  foci;  and,  when 
such  evidence  is  present,  even  though  we  have  not  been  able  to 
locate  the  lesion,  let  us  accept  it  as  a  tangible  proof  of  our  limita- 
tions rather  than  an  instance  of  nature's  specific  reaction  gone 
wrong. 

Variability  of  Tuberculins. — At  this  point  permit  me  to  call 
attention  to  an  important  factor  which  is  probably  militating 
against  exactness  in  the  tuberculin  tests.  We  know  that  differ- 
ent skins  react  differently;  that  the  degree  of  reaction  depends 
upon  the  reactive  powers  of  the  patient;  that  it  is  influenced  by 
certain  infections;  and  that  it  is  further  influenced  by  the 
method  of  making  the  test;  but  I  desire  to  call  attention  to  an- 
other source  of  difficulty  in  interpretation  which  lies  in  the  tu- 
berculin  itself.     Tuberculin   made   by   different   manufacturers 


602  DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 

differs  greatly  in  its  strength  and  in  the  percentage  of  com- 
ponent parts  of  the  tubercle  bacillus  which  it  contains.  During 
recent  years  I  have  made  a  careful  study  of  the  character  of 
the  reaction  following  the  von  Pirquet  test.  In  this  I  have  used 
Koch's  Old  Tuberculin,  full  strength.  I  have  found  that  the 
preparations  made  by  some  manufacturers  would  give  a  reac- 
tion twice  or  three  times  as  strong  as  the  tuberculin  made  by 
others.  It  is  very  desirable  to  have  some  method  of  standardiz- 
ing these  reactions.  If  we  have  a  tuberculin  which  contains 
comparatively  few  of  the  principles  of  the  tubercle  bacillus, 
which  are  active  in  producing  a  reaction,  we  can  readily  see 
that  the  maximum  reaction  from  this  preparation  would  be 
decidedly  small,  as  compared  with  one  which  was  rich  in  these 
active  principles.  After  observing  this  fact  I  made  the  com- 
parison of  several  different  preparations  and  found  that  the 
tuberculin  made  by  one  manufacturer  gave  a  maximum  reaction 
of  %  cm.  in  diameter,  in  the  same  patient  in  which  a  prepara- 
tion made  by  another  manufacturer  gave  a  reaction  of  IV2  to 
2  cm.  From  this,  it  can  be  seen  that  the  reaction  of  y2  cm. 
would  be  considered  a  moderately  severe  reaction,  when  inter- 
preted in  the  terms  of  the  second  preparation. 

The  importance  of  this  is  evident  because  a  prompt  maximum 
reaction  accompanies  activity  in  a  tuberculous  process  in  an  in- 
dividual with  good  reactive  powers,  while  a  slight  reaction  com- 
ing on  slowly,  is  rarely  found  in  one  fighting  an  active  infection. 

The  diagnosis  of  early  active  pulmonary  tuberculosis  is  not  an 
easy  matter  unless  the  infection  possesses  considerable  viru- 
lence and  results  in  the  formation  of  many  toxins,  or  the  lesion  is 
fairly  extensive.  We  must  disabuse  our  minds  of  the  thought 
that  we  are  diagnosing  the  disease  as  soon  as  it  affects  the  pul- 
monary tissue.  Occasionally  it  is  weeks,  but  more  often  months 
and  years  after  the  implantation  of  the  bacillus  and  the  produc- 
tion of  the  first  fibroid  area  that  activity  again  shows  itself,  and 
an  extension  of  the  disease  takes  place  with  a  production  of  the 
symptoms  which  we  have  learned  to  recognize  as  belonging  to 
early  pulmonary  tuberculosis. 

The  examination  of  the  lung,  however,  can  be  approached  in 
so  many  ways  that  when  our  data  is  all  correlated,  we  are  in  a 


CLINICAL   HISTORY   AND   DIAGNOSIS  603 

position  to  give  a  fairly  accurate  opinion.  By  the  time  the  in- 
formation obtained  from  clinical  history,  physical  examination, 
sputum  examination,  tuberculin  tests,  and  the  x-ray  are  cor- 
related, the  per  cent  of  error  will  be  no  greater  than  in  any 
other  field  of  diagnosis,  made  by  an  examiner  of  equal  skill. 

Importance  of  Clinical  History  in  Diagnosis. — The  importance 
of  obtaining  an  accurate  clinical  history  seems  to  be  generally 
underestimated,  at  least  in  practice.  While  it  is  true  that  some 
of  the  symptoms  of  which  the  patient  complains  are  of  little 
differential  diagnostic  worth  and  could  be  produced  by  other 
pathological  conditions,  yet  there  are  others  that  have  greater 
significance.  If  the  history  is  carefully  and  fully  taken,  there 
will  usually  be  enough  symptoms  elicited  to  point  definitely  to  a 
pulmonary  tuberculosis  and  make  such  a  diagnosis  a  probability. 

In  the  grouping  of  symptoms  according  to  their  etiology1  I 
have  endeavored  to  show  the  relative  importance  of  the  different 
groups  of  symptoms  of  early  tuberculosis  and  their  diagnostic 
value.  Those  due  to  toxemia  such  as  malaise,  feeling  of  being 
run  down,  lack  of  endurance,  nervous  instability,  indigestion, 
and  loss  of  weight,  rapid  heart  action,  night  sweats  and  temper- 
ature do  not  point  to  anything  definite.  They  could  be  caused 
by  a  pulmonary  or  a  glandular  tuberculosis  or  a  lesion  in  most 
any  tissue  of  the  body,  or  to  a  non-tuberculous  toxemia  of  light 
degree.  Consequently,  they  alone  are  of  little  diagnostic  aid. 
But,  when  the  lung  is  involved,  they  rarely  occur  alone.  One 
or  more  of  those  of  reflex  origin,  such  as  hoarseness,  tickling  in 
the  larynx,  cough,  indigestion  with  loss  of  weight,  chest  pains, 
particularly  aching  of  the  shoulders  and  over  the  apices  and 
upper  portion  of  the  lung,  increased  pulse  rate  and  flushing  of 
the  face,  are  almost  sure  to  be  present  if  the  focus  is  active;  so, 
also,  one  or  more  of  those  due  to  the  tuberculous  process  per  se, 
such  as  frequent  and  protracted  colds,  spitting  of  blood,  pleur- 
isy, sputum,  and  rise  of  temperature. 

Hoarseness  or  tickling  in  the  throat,  when  due  to  a  tubercu- 
lous irritation,  with  or  without  cough  or  expectoration,  is  nearly 


JThe  Altered  Condition  of  the  Neck  and  Chest  Muscles  and  Subcutaneous  Tissue  Over- 
lying Them  as  Important  Aids  in  the  Early  Diagnosis  of  Tuberculosis,  Northwest  Medicine, 
1915,  vol.  vii,  No.  6,  June;  and  A  Classification  of  the  Symptoms  of  Early  Pulmonary 
Tuberculosis  Based  on  Their  Etiology,   St.   Paul  Medical  Journal,   1915,  vol.  xvii,  No.    1. 


604  DIAGNOSIS   AND  DIFFERENTIAL  DIAGNOSIS 

always  accompanied  by  some  of  the  toxic  symptoms  above  men- 
tioned, and  this  combination  should  point  to  the  lung.  Local 
lesions  in  the  larynx  of  a  simple  nature  which  cause  persistent 
hoarseness  or  inclination  to  cough  are  not  apt  to  be  accom- 
panied by  toxic  symptoms.  When  sufficient  irritation  is  pres- 
ent in  the  lung  to  produce  reflex  hoarseness  and  cough,  either 
the  diaphragm  reflex  or  the  spasm  of  the  superficial  muscles,  or 
both,  are  practically  certain  to  be  present ;  and,  if  so,  add  greatly 
to  our  suspicion  of  an  inflammation  in  the  lung.  The  more  ex- 
perience I  have  in  the  study  and  employment  of  the  reflex  motor 
phenomena,  as  they  are  found  in  active  pulmonary  tuberculosis, 
the  more  I  depend  upon  them  when  in  doubt. 

A  failure  to  appreciate  the  nature  and  cause  of  the  symptoms 
and  signs  which  accompany  tuberculosis  has  caused  great  con- 
fusion in  the  examiner's  mind  and  made  the  diagnosis  of  this 
disease  extremely  difficult.  Now,  however,  that  we  have  classi- 
fied them  etiologically,  we  can  better  understand  the  different 
manifestations  of  the  disease  and  form  a  more  accurate  concep- 
tion of  the  underlying  pathology  as  expressed  in  the  symp- 
tomatology. 

In  all  organs  which  are  supplied  by  the  sympathetic  division 
of  the  vegetative  system  on  the  one  hand,  and  the  greater  vagus  on 
the  other  hand,  there  is  very  likely  to  be  during  periods  of  toxemia, 
a  general  depression  of  function,  because  the  sympathetics,  being 
centrally  stimulated,  produce  such  an  increased  tonus  that  they  are 
able  to  overcome  the  vagus  tonus  and  destroy  the  normal  physiolog- 
ical balance. 

The  importance  of  understanding  the  nervous  system  in  both 
its  relationship  to  the  lung  and  to  the  toxins  engendered  by  the 
tuberculous  process  cannot  be  overestimated.  Two  of  the  groups 
of  symptoms  which  I  have  described  are  expressions  of  nerve 
stimulation.  The  symptoms  in  one  of  these  groups, — those  of 
toxic  origin — are  due  to  central  stimulation;  while  the  other, — 
those  of  reflex  origin, — are  due  to  peripheral  irritation.  This 
difference,  naturally,  stamps  these  groups  with  a  distinct  in- 
dividuality. In  this  connection,  however,  we  must  not  forget 
the  peripheral  stimulation  of  the  sympathetics  resulting  from 
adrenin. 


CLINICAL   HISTORY   AND   DIAGNOSIS  605 

Symptoms  belonging  to  Group  I  (toxemia)  are  expressions 
of  central  stimulation  plus  a  general  discharge  through  the 
sympathetic  nervous  system  and  manifest  themselves  in  many 
organs  and  tissues  at  the  same  time.  They  are  also  present 
under  several  conditions. 

1.  When  bacilli  in  the  tuberculous  focus  are  multiplying  and 
toxins  are  diffusing  into  adjacent  tissues ;  likewise  when  necrosis 
and  caseation  are  taking  place. 

2.  When,  after  the  acute  inflammation  has  disappeared,  through 
wrong  methods  of  living,  particularly  overexertion,  autoinocu- 
lation  produces  sufficient  toxemia  to  continue  the  irritation  of 
the  sympathetic  nervous  system. 

3.  When,  through  prolonged  action  of  the  toxins  the  normal 
sympathetic  balance  has  been  more  or  less  permanently  dis- 
turbed and  a  condition  of  neurasthenia  has  developed. 

4.  When,  through  fear,  discouragement  and  disappointment, 
as  a  result  of  the  disease  or  for  some  other  cause,  general  sym- 
pathetic stimulation  takes  place. 

While  toxic  symptoms  are  due  to  central  stimulation  of  the 
sympathetics,  and  are  prolonged  by  peripheral  stimulation  by 
adrenin,  reflex  symptoms  are  produced  by  stimulation  of  the 
peripheral  endings  of  the  greater  vagus  and  possibly  also  the 
sympathetic  divisions  of  the  vegetative  system  in  the  inflamed 
area  in  the  lung.  These  symptoms  are  also  widespread,  affect- 
ing many  tissues  and  parts;  but  they  express  themselves  with  a 
wide  degree  of  variability.  At  one  time  or  in  one  organ  the 
symptoms  may  be  the  expression  of  a  vagus  reflex,  while  at  an- 
other time  and  in  another  organ  they  may  be  that  of  a  sympa- 
thetic reflex.  When  the  action  of  both  divisions  affects  the 
same  organ,  as  it  does  in  the  heart,  stomach  and  intestines, 
vagus  tonus  may  predominate  at  one  time  and  sympathetic  at 
another;  and  at  still  other  times,  the  stimulation  through  the 
two  systems  may  balance  each  other  and  maintain  a  normal 
equilibrium. 

When  acute  toxemia  is  present  the  central  stimulation  of  the 
toxins  on  the  sympathetic,  added  to  the  peripheral  irritation  of 
the  sympathetic  nerve  endings  by  the  increased  adrenin  in  the 
blood  and  possibly  also  by  the  inflammation  in  the  lung,  over- 


606  DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 

balances  the  vagus  tonus  in  nearly  every  instance,  with  a  result- 
ant general  depression  of  function  in  the  viscera.  We  now  and 
then  see  notable  exceptions  to  this  rule,  however,  in  that  the 
pulse  rate  will  remain  lower  than  is  common  in  other  fevers, 
of  equal  degree,  during  acute  cavity  formation  in  the  lung. 
Hyperacidity  will  now  and  then  also  increase  in  severity  during 
this  stage  of  increased  toxemia.  The  explanation  for  this  is  that 
the  reflex  irritation  of  the  greater  vagus  is  sufficient  to  preserve 
a  strong  condition  of  vagus  tonus;  if  not  sufficient  to  overcome 
the  effect  of  the  sympathetic,  at  least  sufficient  to  greatly  modify 
it.  The  absence  of  symptoms  of  the  toxic  group  does  not  mean 
that  active  tuberculosis  is  not  present. 

The  symptoms  due  to  reflex  cause  are  variable;  at  one  time  a 
sympathetic  tonus  may  be  most  prominent;  at  another  a  vagus 
reflex  may  predominate  in  the  same  organ.  When  the  condi- 
tions which  are  accountable  for  the  toxic  symptoms  disappear, 
the  remaining  symptoms  depend  on  whether  vagus  or  sympa- 
thetic tonus  predominates.  We  now  find  a  rapid  pulse  due 
to  increased  sympathetic  tonus;  now  one  slower  than  normal 
due  to  increased  vagus  tonus;  now  depressed  secretion  and 
motility  in  the  stomach  and  intestines  as  a  result  of  increased 
sympathetic  tonus ;  and,  again,  an  increase  in  both  functions  due 
to  increased  vagus  tonus.  This  antagonism  is  present  as  long 
as  the  peripheral  nerve  endings  in  these  two  systems  are  irri- 
tated and  the  central  cells  are  stimulated. 

We  should  probably  not  go  far  wrong  if  we  assumed  that 
permanent  injury  follows  this  chronic  stimulation;  and,  that 
some  of  the  degenerative  changes  which  manifest  themselves  in 
the  internal  viscera  of  the  patients  suffering  from  chronic  tuber- 
culosis, are  due  to  this  reflex  irritation.  We  have  analogous 
grounds  for  suspecting  degenerative  changes  in  the  internal  vis- 
cera, in  the  trophic  disturbances  which  manifest  themselves  in 
the  skin,  subcutaneous  tissue,  and  muscles,  as  a  result  of  reflex 
sympathetic  irritation,  as  already  described. 

The  symptoms  due  to  the  tuberculous  process  per  se  are  the 
most  trustworthy  symptoms  in  early  pulmonary  tuberculosis, 
and  one,  or  more,  is  usually  present  comparatively  early  in  the 
disease,  although  they  rarely  show  as  early  as  those  of  toxic 


CLINICAL   HISTORY   AND   DIAGNOSIS  607 

and  reflex  origin.  Frequent  and  protracted  colds  are  common- 
ly present,  but  rarely  occur  except  when  a  fairly  extensive  lesion 
is  present;  but,  when  present,  should  always  make  us  think  of  pul- 
monary tuberculosis.  It  is  nearly  always  accompanied  by  some 
rise  in  temperature  and  some  of  the  symptoms  of  the  other  two 
groups.  Spitting  of  blood  makes  the  diagnosis  almost  positive  un- 
less some  other  cause  can  be  found ;  so  does  pleurisy.  Pleurisy  and 
spitting  of  blood  may  both  come  on  suddenly  with  few  or  no  symp- 
toms belonging  to  the  other  groups,  although,  of  the  two,  pleurisy 
is  more  apt  to  be  so  accompanied.  If,  instead  of  calling  pleurisy 
by  its  simple  name  we  would  call  it  by  its  true  name,  active 
tuberculosis  of  the  pleura,  we  would  have  far  more  respect  for  it 
and  often  give  our  patients  the  advantage  of  diagnosing  a  tuber- 
culous involvement  when  it  first  announces  its  presence.  Sputum 
containing  bacilli,  while  rarely  present,  may  be  found,  occa- 
sionally, very  early  to  the  great  surprise  of  the  examiner. 
This  follows  sufficiently  often  to  make  it  imperative  on  the 
examiner  to  collect  all  sputum  raised  by  the  patient,  regard- 
less of  his  opinion  as  to  where  it  comes  from,  and  subject  it  to 
one  of  the  more  accurate  tests  for  bacilli.  A  three  days '  quantity 
should  be  taken  in  all  such  cases  and  treated  as  described  fully 
in  Chapter  XX. 

Temperature  as  a  diagnostic  sign  in  tuberculosis  has  lost  some 
of  its  long  time  suspected  value.  Formerly,  clinicians  were  will- 
ing to  make  a  diagnosis  of  tuberculosis  on  a  slight  persistent 
rise  of  temperature  which  could  not  be  assigned  to  any  other 
cause,  even  if  no  other  sign  of  the  disease  could  be  found.  Now, 
that  we  know  there  are  many  lesions  of  localized  infection  such 
as  those  produced  by  microorganisms  of  the  streptococcus  type, 
which  may  cause  persistent  slight  elevation  of  temperature,  we 
are  coming  to  realize  that  differentiation  is  necessary.  Such 
rises  in  temperature  must  be  looked  upon  as  being  a  part  of  the 
general  syndrome  of  toxemia,  and  as  such,  may  be  caused  by 
infections  of  the  tonsils,  teeth,  sinuses,  prostate,  fallopian  tubes, 
or  any  other  organ. 

In  instances  of  hidden  tuberculous  foci  and  hidden  infections 
of  other  types,  differentiation  may  be  very  difficult  for  we  may 
have  the  same  group  of  toxic  symptoms  and  the  same  type  of 


608  DIAGNOSIS   AND   DIFFERENTIAL   DIAGNOSIS 

temperature  curve.  In  such  cases  the  value  of  the  tuberculin 
test  must  not  be  forgotten.  A  positive  well  marked  cutaneous 
reaction  indicates  such  a  sensitized  condition  of  the  cells  as  ac- 
companies an  active  tuberculous  focus;  or  a  reaction  to  the  sub- 
cutaneous injection  indicates  the  same.  Of  course,  infections  of 
both  types  might  be  present  and  this  possibility  must  not  be  over- 
looked. 

From  our  discussion  it  is  now  plain  that  the  only  group  of 
symptoms  which,  unaided,  permits  of  the  making  of  a  definite 
diagnosis  are  those  belonging  to  the  group  caused  by  the  tuber- 
culous process  per  se.  But,  fortunately,  if  the  history  is  taken 
with  sufficient  care,  any  one  important  symptom  or  any  group  of 
symptoms  will  most  likely  be  fortified  by  others.  A  fact  which 
is  often  lost  sight  of  is  that  it  is  just  as  important  to  question 
the  patient  further  regarding  points  in  his  clinical  history  in 
case  of  doubt,  as  it  is  to  reexamine  the  chest,  or  sputum.  Pa- 
tients are  rarely  able  to  give  a  complete,  accurate,  clinical  his- 
tory upon  the  first  interrogation. 

What  Value  Has  Physical  Examination  in  Diagnosis? — The 
physical  examination  of  the  chest  is  the  procedure  upon  which 
the  decision  as  to  the  presence  or  absence  of  pulmonary  tuber- 
culosis finally  rests.  When  one  recalls  the  few  changes  which 
small  early  lesions  cause  in  the  pulmonary  tissue,  and  the  dif- 
ficulties which  beset  the  usual  methods  of  examination,  he  is 
forced  to  believe  that  reliance  on  physical  findings  by  men  with 
insufficient  training  or  experience  is  militating  against  truly 
early  diagnosis.  This  is  particularly  true  with  our  present  short- 
comings in  physical  diagnosis.  This  is  not  said  to  discourage 
the  making  of  physical  examinations,  but  in  recognition  of  a 
fact  which  is  militating  against  early  diagnosis.  With  the  more 
intensive  teaching  of  today,  however,  there  should  be  no  more 
excuse  for  failing  to  examine  chests  properly  than  for  failure 
in  any  other  line. 

As  long  as  we  are  led  to  believe  that  early  pulmonary  tubercu- 
losis is  easy  to  find  on  physical  examination,  so  long  will  exami- 
nations be  made,  and,  failing  to  discover  a  lesion,  the  patient  be 
told  that  his  lungs  are  free  from  tuberculosis.  Expert  examiners 
are  beginning  to  realize  that  the  truly  early  cases  cause   ex- 


PHYSICAL  EXAMINATION  AND   DIAGNOSIS  609 

ceedingly  slight  changes  in  the  tissues;  and  that  the  truly  in- 
cipient pulmonary  tuberculosis — that  entity  concerning  which 
they  have  talked  and  dreamed — is  so  unfamiliar  to  them  that 
they  would  scarcely  recognize  it  when  making  examinations 
by  the  usual  physical  methods. 

The  findings  on  physical  examination  of  moderately  advanced 
tuberculous  lesions  are  fairly  well  known.  They  have  unfor- 
tunately been  described  as  belonging  to  incipient  tuberculosis. 
This  fact  can  be  appreciated  when  we  fully  realize  that  adult 
pulmonary  tuberculosis  is  a  chronic  infection;  at  first,  usually 
small  and  fibroid  in  character,  because  it  is  an  infection  which 
takes  place  after  the  patient  has  become  partially  immunized 
against  the  bacillus.  The  protective  sensitization  of  the  cells 
prevents  it  from  extending  rapidly.  Its  very  slowness  of  develop- 
ment minimizes  the  symptoms  present ;  and  so  the  disease  usually 
arrives  at  such  a  degree  of  activity  that  exudation  has  taken 
place  in  the  surrounding  tissues,  the  lesion  has  become  some- 
what extensive  and  conditions  are  present  for  a  fairly  rapid  pro- 
gression of  the  process  before  it  is  recognized  clinically.  Instead 
of  calling  this  incipient  tuberculosis,  it  is  more  appropriately 
named  clinically  active  tuberculosis.  This  offers  signs  which 
may  be  detected  by  the  usual  methods  of  physical  examination; 
but  even  this  is  not  always  easy  to  detect.  This  process  may 
follow  months  and  even  years  after  the  incipient  lesion. 

The  lesson  that  this  impresses  upon  us  is  to  realize  the  short- 
comings of  our  older  teachings  and  improve  upon  them.  It 
emphasizes  the  fact  that  signs  on  percussion  and  auscultation 
may  be  so  slight  as  to  go  unrecognized,  yet  a  tuberculous  lesion 
be  present.  Progress  is  not  apt  to  be  made  unless  the  necessity 
for  such  is  recognized,  and  it  is  in  that  spirit  that  we  approach 
this  difficult  subject.  If  all  who  examine  chests  would  only  ap- 
preciate these  difficulties,  as  those  do  who  are  expert  examiners, 
and,  in  case  of  doubt,  make  the  final  diagnosis  not  so  much  on 
the  physical  findings  alone  as  from  a  careful  analysis  of  all 
the  data  derived  from  clinical  history,  physical  examinations, 
tuberculin  tests,  sputum  examinations,  and  x-ray  findings,  the 
results  from  the  standpoint  of  the  patient  would  be  far  more 
satisfactory. 


610  DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 

There  is  no  use  disputing  over  the  character  of  the  breath 
sounds  in  early  tuberculosis,  for  it  may  be  rough;  it  may  be 
harsh ;  it  may  be  both ;  expiration  may  be  prolonged  or  not.  The 
character  of  the  sound  will  vary  according  to  the  condition  of  the 
tissues,  whether  it  be  a  new  lesion  or  a  lighting  up  of  an  old 
focus,  and  upon  the  extent  of  both  the  old  and  the  new,  when 
present,  as  described  on  page  429.  The  same  may  be  said  of 
percussion.  The  normal  side  may  show  the  highest  percussion 
note  when  the  soft  structures  on  the  other  side  have  atrophied, 
as  they  do  in  the  presence  of  chronic  inflammations  in  the  lungs, 
as  described  on  page  422. 

In  case  an  active  clinical  pulmonary  tuberculosis  is  suspected 
from  clinical  history,  and  yet  the  diagnosis  is  in  doubt  on  ac- 
count of  negative  findings  on  auscultation  and  percussion,  I 
would  suggest  that  its  presence  or  absence  can  almost  certainly 
be  determined  by  the  presence  or  absence  of  the  diaphragm  re- 
flex (lagging  of  the  side)  and  the  motor  reflex  (spasm)  as  it 
affects  the  neck  and  chest  muscles,  particularly  the  sternocleido- 
mastoideus,  trapezius,  and  levator  anguli  scapula?,  as  described 
on  page  410.  "While  these  alterations  in  function  may  be  produced 
by  any  inflammatory  condition  in  the  lungs,  yet  they  are  ex- 
tremely important  in  their  diagnostic  weight  when  tubercu- 
losis is  suspected  from  other  signs  and  symptoms,  and  while 
most  of  the  early  symptoms  are  temporary,  these  muscle  changes 
(spasm)  last  as  long  as  the  sympathetic  endings  are  irritated 
by  the  inflammation  in  the  lung. 

An  acquaintanceship  with  the  motor  and  trophic  reflex  as  af- 
fecting the  muscles  of  respiration  including  the  diaphragm  and 
the  skin  and  subcutaneous  tissue  covering  the  neck  and  chest 
muscles,  as  described  on  page  405,  will  afford  the  examiner^  most 
helpful  information  in  these  difficult  cases. 

The  position  of  the  sputum .  examination  in  the  diagnosis  of 
what  is  usually  termed  early  tuberculosis  can  be  made  of  far 
more  value  than  it  is.  The  common  methods  of  taking  only  a 
sample,  or  even  telling  the  patient  to  clear  out  his  throat  mucus 
in  the  morning  and  save  that  immediately  following,  are  subject 
to  great  error.  In  these  early  cases  bacilli  may  be  present,  but 
they  are  not  apt  to  be  present  in  all  the  mucus  raised.    The  sur- 


X-RAY  AND  DIAGNOSIS  611 

est  method  of  finding  them  consists  in  taking  a  twenty-four  hour, 
or  a  three  day,  sample  and  digesting  and  homogenizing  it  as  men- 
tioned on  page  534.  In  this  way  the  error  is  greatly  minimized. 
Sometimes  when  bacilli  are  absent  a  high  lymphocyte  count  may 
be  present  (Wolff-Eisner).  This  is  extremely  suspicious  of 
tuberculosis.  So  is  the  albumin  content  in  the  sputum  of  some 
diagnostic  merit. 

The  X-ray  in  the  Early  Diagnosis  of  Tuberculosis. — Various 
opinions  are  held  regarding  the  value  of  the  x-ray  in  the  diag- 
nosis of  early  tuberculosis.  It  is  of  great  value  when  used  by 
an  expert.  It  must  always  be  remembered  that  it  has  serious 
limitations.  No  one  except  an  expert  should  make  a  diagnosis 
of  clinical  tuberculosis  from  an  x-ray  plate  alone.  The  findings 
may  be  positive,  yet  the  process  may  be  healed.  If,  however, 
clinical  symptoms  are  present  and  physical  signs  particularly 
reflex  motor  disturbance  and  x-ray  findings  are  positive,  then 
the  x-ray  is  of  value  in  giving  important  confirmatory  evidence. 
The  x-ray  as  used  by  the  average  operator  gives  no  reliable  data 
on  which  to  base  a  diagnosis  of  truly  incipient  tuberculosis. 
There  is  no  doubt,  however,  that  even  a  poor  x-ray  will  make  the 
diagnosis  earlier  than  many  of  the  careless  clinical  examinations. 
It  is  on  a  par  with  a  poor  physical  examination.  The  best  work 
in  pulmonary  rontgenoscopy,  however,  as  studied  and  compared 
with  the  best  work  of  clinicians,  the  comparison  being  made  by 
the  clinicians  themselves,  has  helped  to  elucidate  many  problems 
and  has  advanced  the  science  of  diagnostics  very  materially.  The 
x-ray  is  particularly  valuable  in  hilus  lesions;  and  in  this  con- 
nection I  desire  especially  to  emphasize  its  value  in  the  diagnosis 
of  tuberculosis  of  the  bronchial  glands  in  children.  But  here 
the  findings  are  of  real  importance  only  as  they  are  taken  in  con- 
nection with  the  clinical  history.  For  further  discussion  see 
Chapter  XIX. 

The  fluoroscopic  examination  of  the  chest  is  important.  The 
study  of  the  motion  of  the  diaphragm  will  often  give  valuable 
information.  The  patient  should  be  observed  both  during  quiet 
and  forced  respiration,  remembering  that  a  limited  excursion 
of  the  diaphragm  may  show  on  quiet  respiration  and  be  entirely 
overlooked  on  deep  breathing. 


612  DIAGNOSIS   AND  DIFFERENTIAL.  DIAGNOSIS 

DIFFERENTIAL  DIAGNOSIS. 

General  Asthenic  Constitution. — It  is  often  difficult  to  deter- 
mine whether  or  not  a  person  of  general  asthenic  build  is  also 
suffering  from  a  tuberculous  infection.  Such  individuals  show 
many  of  the  characteristics  of  the  one  with  semi-quiescent  tuber- 
culosis. The  want  of  energy,  lack  of  endurance,  and  gradual  de- 
velopment of  the  irritable  nervous  state,  coming  on  as  they  so 
often  do  in  both  conditions  immediately  after  puberty,  makes 
them  extremely  difficult  to  differentiate  at  times.  If  tubercu- 
losis is  primarily  the  cause  of  the  asthenic  condition,  or  if  it 
is  present  as  a  complication,  it  often  remains  of  the  hidden  type 
for  a  long  time.  Even  if  localized  in  the  lungs  it  may  not  be 
detected  early  owing  to  its  slow  progress.  In  the  case  of  hid- 
den tuberculosis  the  tuberculin  test  becomes  a  very  important 
diagnostic  measure;  and,  even  it  may  prove  of  negative  value. 
Under  such  conditions  a  probable  diagnosis  is  all  that  can  be 
made.  If  the  infection  is  in  the  pulmonary  tissue,  the  doubt 
should  be  removed  by  methods  already  mentioned  in  the  early 
part  of  this  chapter.  The  reflex  signs  and  symptoms,  and  the 
symptoms  due  to  the  tuberculous  process  per  se  are  of  far  greater 
diagnostic  value  than  those  of  toxic  origin  in  these  cases,  and, 
when  present  make  the  diagnosis  easier. 

Neurasthenia. — Neurasthenia  may  be  caused  by  many  different 
conditions,  including  tuberculosis.  At  times  it  offers  the  same 
difficulties  of  diagnosis  as  the  general  asthenic  condition.  Its  re- 
lationship to  the  toxemia  of  tuberculosis  must  not  be  lost  sight 
of.  A  hidden  or  unsuspected  tuberculous  lesion  is  often  the  un- 
derlying cause  and  should  always  be  considered  where  the 
etiology  of  neurasthenia  is  vague.  See  Chapter  VI  for  a  more 
complete  description  of  this  relationship. 

Malaria. — Malaria  is  particularly  confusing  in  districts  where 
prevalent.  The  toxic  symptoms  of  early  active  tuberculosis  so 
closely  resemble  those  of  malaria  that  it  is  no  wonder  that  er- 
roneous diagnoses  are  made.  Care  on  the  part  of  the  examiner, 
however,  will  differentiate  the  two,  particularly  if  the  lesion 
be  pulmonary.  Finding  the  parasite  in  the  blood  settles  the  diag- 
nosis.   One  should  remember,  however,  that  both  may  be  present. 


BRONCHITIS  AND   TUBERCULOSIS  613 

Acute  or  Subacute  Bronchitis. — The  differentiation  between 
simple  bronchitis  and  early  pulmonary  tuberculosis  is  at  times 
difficult  to  make,  particularly  if  the  bronchitis  is  prolonged  in 
its  course. 

Bronchitis  often  comes  on  as  a  cold  in  the  head  or  infection 
of  the  upper  respiratory  tract  and  extends  downward,  although 
at  times  the  first  symptoms  are  on  the  part  of  the  lower  tract. 
Tuberculosis,  on  the  other  hand,  begins  in  the  lungs.  In 
bronchitis  the  attack  is  apt  to  be  more  sudden  in  its  onset  and 
the  symptoms  more  severe,  although  this  varies  greatly  with 
different  attacks.  Cough  usually  appears  suddenly  and  is  har- 
assing in  bronchitis,  while  it  is  of  gradual  onset  and  milder  in 
tuberculosis.  Temperature  is  usually  elevated  at  first  and  drops 
after  a  day  or  two  in  bronchitis ;  but  it  is  persistent  if  due  to  ac- 
tive tuberculosis;  or,  if  due  to  a  sleeping  focus  which  has  been 
aroused  to  activity.  Kales  may  be  present,  either  fine,  or  coarse 
and  bubbling,  or  dry  sonorous,  or  sibilant  in  bronchitis,  and  are, 
as  a  rule,  scattered  over  considerable  lung  area;  while  in  tuber- 
culosis they  are  confined  to  a  smaller  circumscribed  area,  usually 
near  the  apex,  and  are  accompanied  by  percussion  changes  and 
disturbed  function  on  the  part  of  the  diaphragm  and  other  re- 
spiratory muscles.  The  motor  reflex  is  not  present  in  bronchitis 
unless  pulmonary  tissue  is  inflamed.  The  tuberculin  test  is  often 
of  value  when  sputum  is  absent.  A  bronchitis,  accompanied  by 
toxic  symptoms,  which  persist  for  more  than  a  few  days,  is  sus- 
picious of  tuberculosis. 

Intercostal  Neuralgia. — The  diagnosis  of  intercostal  neuralgia 
is  often  made  when  tuberculosis  of  the  pleura  is  the  pathological 
process  present.  Intercostal  neuralgia  is  an  exceedingly  rare 
condition  per  se,  while  tuberculous  pleurisy  is  common.  Judg- 
ing from  the  diagnoses  made,  the  opposite  would  seem  true. 
Any  pain  which  seems  like  an  intercostal  neuralgia  should  be 
investigated  for  pleurisy  (tuberculosis  of  the  pleura).  One  im- 
portant differential  point  is  that  the  motion  of  the  lung  is  more 
restricted  in  pleurisy  than  in  intercostal  neuralgia,  and  the  pain 
is  more  acute  on  respiration.  It  must  be  remembered  that  there 
can  be  an  inflammation  of  the  pleura  without  any  marked  signs. 
Both  pain  and  the  pleural  rub  may  even  be  absent. 


614  DIAGNOSIS  AND  DIFFEEENTIAL  DIAGNOSIS 

Influenza. — Sometimes  clinical  tuberculosis  is  suddenly  ushered 
in  with  symptoms  resembling  those  of  influenza.  This  usually 
comes  in  one  who  has  been  somewhat  below  par  for  a  time,  yet 
in  whom  the  symptoms  were  so  slight  that  they  were  not  recog- 
nized until  the  more  acute  symptoms  manifested  themselves.  A 
chill  followed  by  fever  and  other  toxic  symptoms,  cough  and  free 
expectoration,  all  within  a  few  days,  is  the  picture.  The  exami- 
nation of  the  sputum  in  such  cases  usually  affords  a  surprise  to 
the  unsuspecting  clinician  and  makes  the  diagnosis.  The  motor 
reflex  as  shown  in  diminished  action  of  the  diaphragm  and  in- 
creased tonicity  of  the  neck  muscles  is  present  and  of  value  in 
showing  that  pulmonary  tissue  is  involved  in  the  inflammation. 
These  attacks  are  all  the  more  confusing  if  they  come,  as  they 
often  do,  during  the  season  when  influenza  is  prevalent. 

Aside  from  the  influenzal  type  of  onset,  there  is  a  close  re- 
semblance between  the  usual  exacerbation  in  tuberculosis  and 
influenza.  Tuberculous  patients  often  complain  of  repeated  at- 
tacks of  la  grippe.  Under  such  circumstances,  the  very  fact  of 
the  repeated  attacks  should  arouse  suspicion  that  the  process  is 
probably  of  a  tuberculous  nature,  and  cause  the  sputum  to  be 
carefully  searched  for  bacilli,  and  other  means  of  differentiation 
to  be  used. 

Chronic  Purulent  Bronchitis  and  Bronchiectasis. — Not  only  are 
there  difficulties  in  differentiating  between  early  tuberculosis  and 
other  lesions  in  the  lung,  but  even  advanced  tuberculosis  must 
often  be  differentiated  from  other  widespread  non-bacillary  in- 
fections. 

Chronic  bronchitis  and  bronchiectasis,  with  the  large  quantities 
of  sputum  which  are  often  present,  and  the  evidence  of  loss  of 
tissue  and  cavity  formation  and  the  tendency  to  exacerbation, 
is  often  extremely  difficult  to  differentiate  from  tuberculosis. 
The  difficulty  is  increased  by  the  fact  that  chronic  tuberculosis 
may  be  accompanied  by  large  quantities  of  sputum,  and  yet 
not  show  bacilli.  Cavities,  at  times,  suppurate  long  after  bacilli 
disappear.  On  the  other  hand,  cases  may  be  free  from  bacilli 
for  years  and  be  considered  as  simple  bronchitis  and  then  show 
bacilli.  A  patient  who  had  been  under  the  care  of  a  confrere 
for  fourteen  years   recently   consulted  me.     At  no   time   had 


CHRONIC   FIBROSIS   AND   TUBERCULOSIS  615 

bacilli  been  found  in  the  sputum.  Immediately  prior  to  her 
consulting  me,  she  had  a  rise  of  temperature  and  suffered  from 
malaise  and  loss  of  weight.  To  her  great  surprise  bacilli  were 
found.  Three  possibilities  must  be  considered  in  this  case;  the 
first,  that  this  was  a  case  of  chronic  bronchitis  which  eventually 
involved  tuberculous  tissue  causing  a  breaking  down  of  the  protec- 
tive envelope  with  the  escape  of  bacilli ;  second,  that  it  was  origi- 
nally a  tuberculosis  which  left  the  patient  with  a  suppurating 
cavity  from  which  the  bacilli  disappeared  not  to  return  again 
until  the  time  of  her  consulting  me;  and,  third,  that  bacilli  were 
given  off  from  time  to  time  during  active  periods  without  be- 
ing discovered.  Previous  examinations  had  always  been  con- 
fined to  the  examination  of  a  sample  of  sputum,  while  I  took 
a  twenty-four  hour  specimen  and  submitted  it  to  digestion,  and 
homogenization  with  the  shaking  machine  before  making  the 
slide.  I  wish  to  urge  the  importance  of  such  a  procedure  in  all 
such  cases  as  being  far  more  satisfactory  than  the  examination 
of  single  or  repeated  specimens.  The  patient  also  responded 
promptly  to  the  cutaneous  tuberculin  test  with  a  marked  re- 
action, and  from  this  alone  I  would  have  felt  sure  that  there 
was  an  active  tuberculous  element  in  the  case.  In  order  to 
fully  understand  the  necessity  of  examining  twenty-four  or 
seventy-two  hour  specimens  after  homogenization,  see  Chap- 
ter XX. 

Chronic  Fibrosis. — We  often  find  an  increased  density  of  tis- 
sue over  a  considerable  portion  of  a  lobe,  usually  the  upper, 
when  making  a  physical  examination  of  the  lung.  Sometimes  it 
is  more  marked  near,  and  extending  some  distance  into  the  lung 
tissue  from  the  hilus.  Auscultation  often  reveals  a  diminished 
murmur  at  times  with  increased  harshness  and  sometimes  with 
prolonged  expiration.  Such  a  condition  may  be  present  for  a 
long  time  without  producing  recognizable  symptoms,  although 
usually  there  is  a  gradual  impairment  of  health. 

I  am  coming  to  believe  that  most  of  such  cases  are  tuberculous 
in  nature  from  the  first,  and  that  they  are  produced  by  an  organ- 
ism of  low  virulence  which  stimulates  to  new  tissue  formation 
instead  of  necrosis.  Sooner  or  later,  however,  these  processes 
undergo  necrosis  and  assume  the  usual  fibro-ulcerative  type.    The 


616  DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 

diagnosis  in  these  cases  is  rarely  made  until  necrosis  occurs  with 
the  appearance  of  bacilli  in  the  sputum,  although  this  is  usually 
preceded  by  a  history  of  general  decline  in  health  lasting  for  a 
variable  time.  The  x-ray  is  of  value  in  these  cases  but  is  rarely 
employed  unless  accidentally,  for  it  is  rarely  that  the  lungs  are 
suspected,  because  there  are  no  particular  signs  except  those  of 
gradual  loss  of  strength  until  the  temperature  stage  which  pre- 
cedes or  attends  ulceration  is  reached. 

Pulmonary  Infarct. — An  infarct  of  a  small  pulmonary  ves- 
sel may  at  times  be  difficult  to  differentiate  from  a  tuberculous 
lesion.  When  the  source  of  the  embolus  is  plain  it  is  not  so 
difficult;  but,  if  the  seat  is  hidden,  as,  for  example,  in  one 
of  the  deep  veins,  doubt  may  arise.  If  it  is  a  large  pulmonary 
vessel  which  is  occluded,  physical  signs  may  be  detected;  but  on 
the  other  hand  the  vessel  may  be  so  small  as  to  preclude  any 
changes  in  percussion  or  auscultation.  If  near  the  surface,  pleu- 
risy is  usually  present,  and  motor  disturbance  on  the  part  of 
the  diaphragm  will  be  noted.  Bales  may  or  may  not  be  present 
according  to  the  size  of  the  infarct.  Pain  is  the  most  common 
symptom.  It  is  usually  the  first  one  noticed.  It  resembles  the 
usual  pain  of  pleurisy;  which  means,  that  it  shows  great  vari- 
ability. It  may  be  dull  or  sudden  or  sharp  in  onset;  and  may, 
particularly  if  it  affects  the  diaphragm,  be  felt  in  the  upper  ab- 
domen and  shoulder.  It  may  be  a  slight  discomfort  or  an  acute 
pain  brought  on  by  cough  and  deep  breathing.  Expectoration 
of  blood  is  a  common  symptom  and  only  secondary  in  importance 
to  pain.  The  blood  may  be  slight  in  amount,  or  very  profuse. 
It  rarely  shows  as  bright  blood,  but  usually  as  tenacious,  dark 
clots.  With  such  symptoms  it  might  be  quite  difficult  to  deter- 
mine whether  or  not  tuberculosis  or  embolism  is  the  cause.  The 
character  of  the  blood  and  the  previous  history  of  the  patient 
are  important  factors.  The  fact  that  infarcts  are  more  apt  to  oc- 
cur in  the  lower  lobes,  while  tuberculosis  usually  affects  the  up- 
per lobes  first,  is  also  important.  In  infarct  the  symptoms  are 
usually  more  sudden  than  in  tuberculosis.  The  fact  that  infarct 
usually  comes  on  in  patients  with  cardiac  disease  or  venous 
thrombosis  is  especially  suggestive.    Infarct  usually  runs  a  course 


PNEUMONIA  AND   TUBERCULOSIS  617 

with  slight  or  no  fever,  but  so  does  tuberculosis  at  times.  The 
tuberculin  test  may  give  important  information. 

Pneumonia. — It  is  a  very  common  experience  for  physicians, 
on  being  called  to  see  a  patient  for  the  first  time,  to  make  a 
diagnosis  of  pneumonia  if  they  find  fever  present  and  an  altered 
percussion  note  over  the  chest  with  rales  in  the  underlying  lung. 
This  diagnosis  is  made  all  too  readily.  The  preceding  history 
should  be  taken  into  consideration,  the  mode  of  the  onset  in- 
quired into  and  the  whole  symptom-complex  should  be  carefully 
analyzed  before  such  a  diagnosis  is  made. 

Pneumonia,  usually,  begins  with  sudden  onset,  while  tuber- 
culosis usually  shows  a  definite  history  of  antecedent  decline  in 
health.  A  careful  history  alone  should  nearly  always  prevent 
a  mistaken  diagnosis.  For  the  symptoms  of  tuberculosis  to  be 
so  pronounced  as  to  be  mistaken  for  pneumonia,  with  the  excep- 
tion of  those  acute  exacerbations  which  simulate  influenza,  there 
should  be  a  definite  antecedent  history  showing  the  presence  of 
some  of  the  most  important  symptoms  extending  over  a  period 
of  weeks  and  often  months.  Malaise,  lack  of  endurance,  and 
feelings  of  gradual  loss  of  strength  would  usually  precede  such 
a  widespread  infection,  while  cough  and  temperature  could 
hardly  be  expected  to  be  absent.  Careful  examination  should 
also  reveal  the  fact,  if  the  focus  is  of  tuberculous  origin,  that  it 
began  at  or  near  the  apex  of  the  lung ;  while,  if  it  is  pneumonia, 
the  signs  are  usually  in  the  middle  or  lower  portion  of  the  lung, 
although  either  may  begin  in  any  part. 

Lobar  pneumonia  is  usually  readily  diagnosed,  but  broncho- 
pneumonia is  the  one  which  offers  difficulties  and  is  more  often 
confused  with  tuberculosis.  Physicians  seem  to  dread  making  a 
diagnosis  of  tuberculosis  if  they  can  avoid  it;  the  habit  is  all  too 
common  of  calling  any  acute  disease  in  the  lungs  either  bronchitis 
or  pneumonia.  The  curability  of  early  tuberculosis  and  the 
seriousness  of  late  tuberculosis,  should  be  sufficient  to  compel 
that  the  tuberculous  patient  be  given  the  benefit  of  the  doubt. 
The  examination  of  the  sputum  will  usually  be  sufficient,  if  care- 
fully made,  to  reveal  the  bacilli.  They  are  nearly  always  pres- 
ent when  such  acute  symptoms  occur.  Repeated  examinations 
should  be  made  if  the  first  are  negative.    A  negative  result  on  ex- 


618  DIAGNOSIS   AND  DIFFERENTIAL  DIAGNOSIS 

amination,  however,  does  not  preclude  the  tuberculous  nature 
of  the  disease. 

If  the  diagnosis  is  not  made  during  the  acuteness  of  the  ill- 
ness, a  delayed  convalescence  should  make  the  diagnosis  almost 
certain. 

The  tuberculin  test  is  unreliable  in  differentiating  these  con- 
ditions because  tuberculosis  may  not  give  a  reaction  during  the 
acuteness  of  the  process.  A  marked  reaction,  on  the  other  hand, 
would  give  valuable  information.  The  test  should  be  employed, 
but  too  much  reliance  should  not  be  placed  on  the  evidence  ob- 
tained. 

Pulmonary  Syphilis. — Pure  syphilis  of  the  lung  is  not  a  com- 
mon disease,  yet  it  is  one  that  must  be  differentiated  from  tuber- 
culosis at  times.  It  is  not  unlikely,  however,  that  the  two  dis- 
eases are  at  times  found  coincidentally. 

It  is  well  to  bear  in  mind  that  no  one  has  been  able  to  con- 
trol his  ancestors  and  consequently  anyone  may  be  infected  with 
syphilis;  and  no  one  has  been  able  to  control  his  environment 
during  early  years,  consequently  anyone  may  have  tuberculosis. 
These  diseases  may  be  associated  or  they  may  be  found  inde- 
pendently. Each  of  them  might  infect  the  lung.  Tuberculosis 
usually  affects  the  lungs  in  adults;  syphilis  usually  affects  non- 
pulmonary  tissues. 

Points  of  differential  value  in  diagnosis  are :  tuberculosis 
usually  begins  at  the  apex,  while  syphilis  usually  begins  at  the 
hilus  or  base.  Syphilis  elsewhere  in  the  body,  with  a  typical 
pulmonary  infection  starting  at  the  hilus  or  base,  unaccompanied 
by  bacillus  bearing  sputum,  forms  a  basis  for  the  diagnosis  of 
syphilis;  so  does  a  positive  Wassermann  with  negative  sputum 
and  negative  tuberculin  tests  in  atypical  lesions.  The  thera- 
peutic tests  are  of  some  value.  Prompt  improvement  under  anti- 
syphilitic  treatment  suggests  a  syphilitic  process. 

The  symptoms  of  advanced  syphilis  may  not  differ  in  any 
particular  from  those  often  observed  in  tuberculosis.  This  can 
be  appreciated  when  it  is  recalled  that  the  symptoms  of  pul- 
monary tuberculosis  are  extremely  variable.  As  a  rule,  the 
symptoms  are  less  acute  when  of  syphilitic  than  when  of  tuber- 
culous origin  for  the  same  amount  of  pathologic  change. 


PULMONARY  SYPHILIS  AND   TUBERCULOSIS  619 

Landis2  discusses  this  subject  as  follows: 

''In  acquired  syphilis  most  writers  describe  two  main  types 
of  the  disease  as  it  occurs  in  the  lungs;  namely,  the  formation 
of  gummata  or  an  extensive  cellular  infiltration  which  leads  to 
fibroid  changes.  If  the  disease  assumes  the  indurative  type,  and 
this  is  by  far  the  most  common  form,  it  usually  originates  at  the 
hilus  of  the  lung  and  extends  outward  along  the  bronchi  and 
blood  vessels.  The  process  is  usually  unilateral,  and  at  most 
involves  only  a  portion  of  one  lobe;  if  several  lobes  are  impli- 
cated it  is  the  portions  which  adjoin  the  root  of  the  lung. 

"In  addition  to  these  types  a  focal  form  has  been  described  in 
which  the  lesion  consists  of  an  area  of  consolidation  and  catarrh. 
It  is  usually  situated  around  the  root  of  the  lung,  and  may  oc- 
cur at  one  apex. 

"Whether  the  disease  manifests  itself  in  the  form  of  gummata, 
as  a  diffuse  fibrosis,  or  as  a  focal  lesion,  most  of  the  cases  re- 
ported indicate  that  the  base  of  the  lung  or  the  area  about  the 
hilus,  rather  than  the  apex,  is  the  part  most  frequently  attacked. 
This  fact  is  usually  cited  as  one  of  the  strong  differential  points 
between  syphilis  and  tuberculosis.  The  general  opinion  has  been 
that  the  apices  are  rarely  involved,  but  it  would  be  rather  sur- 
prising, in  view  of  the  wonderful  diverse  forms  in  which  the 
localization  of  syphilis  manifests  itself,  if  the  upper  portions  of 
the  lungs  should  always  escape. 

"We  believe  that  pulmonary  syphilis  of  a  latent  type  occurs 
far  more  frequently  than  is  usually  supposed.  The  form  to 
which  we  wish  to  call  attention  is  that  in  which  the  localiza- 
tion occurs  in  the  apices  of  the  lungs.  This  type  of  the  disease 
may  simulate  early  pulmonary  tuberculosis  so  closely  as  to  de- 
ceive us  entirely." 

In  discussing  the  diagnosis,  he  further  says: 

"It  is  to  be  noted  that  the  symptoms  in  all  of  these  cases  were 
characteristic  of  pulmonary  tuberculosis;  namely,  morning  cough 
and  expectoration,  blood-streaked  sputum;  loss  of  weight,  and  a 
slight  elevation  of  the  temperature.  In  two  there  was  pain  re- 
sembling that  occurring  in  pleurisy  at  the  base  of  the  right  lung. 


2Latent  Syphilitic  Infection  of  the  Lungs,  American  Journal  of  Medical  Sciences,  August, 
1915. 


620  DIAGNOSIS  AND   DIFFEKENTIAL  DIAGNOSIS 

Furthermore,  they  all  had  physical  signs  indicative  of  incipient 
tuberculosis. 

"If  the  lungs  are  involved,  there  is,  in  addition  to  the  symp- 
toms mentioned  above,  cough,  which  may  be  dry  and  unproduc- 
tive or  accompanied  by  a  moderate  amount  of  greenish  or  yel- 
lowish expectoration.  Blood-streaked  sputum  may  also  occur. 
Pain  at  the  base  of  the  right  lung  is  not  infrequent  and  may  be 
misinterpreted;  it  is  usually  due  to  a  syphilitic  perihepatitis  and 
not  to  pleural  innammation. 

"The  presence  of  latent  syphilis  of  the  lung  is  to  be  suspected 
if  in  addition  to  pulmonary  symptoms  there  are  present  else- 
where in  the  body  lesions  which  are  in  all  probability  luetic  in 
nature,  such  as  a  periostitis,  orchitis,  iritis,  or  suspicious  throat 
lesions.    The  recognition  of  these  cases  should  be  relatively  easy. 

"The  type  of  the  disease  which  offers  the  most  difficulty,  and 
which,  for  the  most  part,  escapes  detection,  is  that  in  which  the 
symptoms  are  entirely  pulmonary  and  in  which  there  are  no  as- 
sociated syphilitic  lesions. 

"The  diagnosis  must  be  made  by  exclusion.  Thus  if  the  symp- 
toms and  physical  signs  are  those  characteristic  of  tubercu- 
losis, and  the  sputum  does  not  contain  tubercle  bacilli,  or  the 
progress  of  the  case  differs  from  that  usually  encountered  in  tu- 
berculosis, the  possibility  of  some  other  exciting  cause  should 
be  thought  of.  Not  only  should  the  sputum  be  examined  for 
organisms  other  than  the  tubercle  bacillus,  but  in  addition,  a 
Wassermann  test  should  be  made  in  every  doubtful  case." 

Actinomycosis. — This  affection  must  sometimes  be  differenti- 
ated from  tuberculosis.  The  differentiation  depends  on  finding 
actinomyces  in  the  sputum.  In  symptoms  and  signs  the  dis- 
ease is  much  the  same  as  many  of  the  atypical  cases  of  tuber- 
culosis. Cough,  sputum,  at  times  accompanied  by  blood,  dyspnea, 
night  sweats,  and  failing  strength  are  the  usual  symptoms.  The 
sputum  was  very  fetid  in  one  of  my  cases,  while  in  another  it 
did  not  differ  especially  from  that  of  tuberculosis. 

This  affection  is  often  found  at  the  bases  instead  of  the  apices, 
although  it  may  affect  the  latter. 

Negative  tuberculin  reactions  and  a  failure  to  find  bacilli  are 
only  negative  evidence.     They  do  not  afford  any  positive  diag- 


MALIGNANT   TUMORS   AND   TUBERCULOSIS  621 

nostic  data.  The  finding  of  actinomyces  is  necessary  for  diag- 
nosis. 

Streptothricosis,  Blastomycosis,  Aspergillosis,  and  Coccidioidal 
Granuloma  are  sometimes  to  be  differentiated  from  tuberculosis. 
These  diseases  are  rare  but  should  be  thought  of  when  the  pul- 
monary lesion  is  atypical.  In  comparison  with  tuberculosis  they 
are  so  rare  that  they  sink  into  insignificance;  but,  for  accuracy 
of  diagnosis,  they  must  be  borne  in  mind.  Their  diagnosis  is 
made  by  finding  the  specific  microorganisms  in  the  sputum. 

Malignant  Tumors  of  the  Lung. — Malignant  tumors  of  the 
lung  may  be  either  primary  or  secondary.  Such  primary 
growths,  however,  are  comparatively  rare.  They  may  be  either 
of  the  sarcomatous  or  carcinomatous  type,  the  former  occurring 
in  early  life,  the  latter  in  late  life.  Probably  two-thirds  of  sar- 
comata occur  before  the  fortieth  year,  and  nearly  all  carcinoma 
after  that  time. 

Of  ten  cases  of  sarcoma  and  cancer  of  the  lung  seen  by  me, 
and  of  which  I  have  notes,  all  were  secondary  but  one.  This  was 
a  primary  cancer,  taking  its  origin  from  the  glands  in  the  left 
superior  bronchus.  The  others  were  metastatic ;  one  a  carcinoma 
primary  in  the  mediastinum;  two,  primary  in  the  stomach;  and 
three,  primary  in  the  breast.  The  other  three  were  sarcomata; 
two,  primary  in  the  femur;  and  one,  primary  in  the  uterus.  In 
one  of  the  sarcomata  the  leg  had  been  amputated  for  sarcoma 
nine  years  previous  to  the  metastatic  manifestations. 

These  growths  may  extend  throughout  more  or  less  of  the  lung, 
and  also  affect  the  pleura  and  structures  of  the  mediastinum. 
The  pericardium  is  not  uncommonly  affected.  Pleural  effusion 
is  not  uncommon  and  adds  greatly  to  the  discomfort  of  the  pa- 
tient, particularly  late  in  the  clinical  course  of  the  disease. 

The  symptoms  vary  greatly  in  different  cases  according  to  the 
structures  involved.  An  irritating  cougli  which  slowly  increases 
in  severity  is  common.  This  is  at  first  unproductive  or  accom- 
panied by  a  small  quantity  of  glary,  pearly,  or,  at  times,  green- 
ish mucus;  the  latter  being  found  rarely  except  when  the  dis- 
ease has  become  somewhat  extensive.  Dyspnea  of  a  progressive 
nature  is  also  common.  This  is  especially  emphasized  on  exer- 
tion.   The  patient  may  be  comfortable  when  quiet,  but,  on  chang- 


622  DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS 

ing  position,  suffers  from  shortness  of  breath.  Temperature,  is, 
as  a  rule,  not  present  early.  I  have  seen  a  rise  to  100°  however, 
as  the  disease  became  advanced  and  showed  signs  of  breaking 
down.  Pain  is,  at  times,  a  factor.  In  the  case  of  my  series, 
which  was  primary  in  the  mediastinum,  there  was  marked  pain 
under  the  sternum  and  in  the  left  arm.  A  very  marked  involve- 
ment was  present  in  the  pericardium  in  this  case.  In  some  of 
the  other  cases,  sharp  cutting  pain  like  that  of  acute  pleuritis 
was  present;  and,  in  two,  considerable  dull  pain  in  the  axillary 
region.  A  feeling  of  fullness  and  compression  is  particularly 
noticed  where  the  growth  spreads  rapidly  and  where  large 
pleural  effusions  are  present.  Hoarseness  and  aphonia  may  ap- 
pear when  the  recurrent  nerve  is  directly  involved.  Difficult 
breathing  or  stridor  is  sometimes  noted  when  pressure  is  made 
on  the  trachea. 

In  differentiating  cancer  and  sarcoma  from  tuberculosis  it 
should  be  borne  in  mind  that  the  toxic  and  most  of  the  reflex 
symptoms  present  in  the  latter  disease,  are  absent;  and  that, 
in  cancer  and  sarcoma,  the  process  in  the  lung  is  usually  wide- 
spread for  the  clinical  symptoms  present.  The  patient  may  be 
in  full  weight  until  near  the  time  that  the  process  becomes  fatal. 
On  the  other  hand,  I  have  seen  cachexia  and  emaciation  the  same 
as  in  pulmonary  tuberculosis. 

The  physical  signs  present  depend  partly  on  where  the  growth 
is  situated.  In  the  centrally  located  growths  there  is  increased 
resistance  on  palpation  and  percussion,  as  well  as  a  dullness  over 
the  areas  surrounding  the  hilus  of  the  lung;  while  in  pure  pul- 
monary metastases  there  are  either  isolated  or  conglomerate 
tumor  masses  in  the  pulmonary  tissue  itself  which  if  large 
enough  produce  the  same  changes. 

The  side  of  involvement  usually  shows  diminished  motion. 
When  located  in  the  mediastinum  pressure  on  the  vessels  at 
times  becomes  great  and  causes  a  dilatation  of  these  on  the 
surface.  Auscultation  may  or  may  not  show  rales.  Diminished 
breathing  may  be  present  when  pressure  is  made  by  the  tumor 
upon  a  bronchus  and  when  air  is  excluded  from  the  pulmonary 
tissue  by  the  tumor  structure.  The  supraclavicular,  cervical  and 
axillary  glands  may  be  the  seat  of  metastatic  infection. 


MALIGNANT   TUMORS  AND   TUBERCULOSIS  623 

The  sputum  may  be  blood-tinged  at  times.  Sometimes  frag- 
ments of  the  tumor  are  found,  and  sometimes  clusters  of  cells 
which  are  considered  as  having  diagnostic  importance. 

The  x-ray  is-  of  value  where  its  findings  are  correlated  with 
that  of  physical  examination  and  clinical  history.  Fig.  105 
shows  the  x-ray  plate  of  one  of  my  cases. 

Diagnosis  of  primary  cancer  in  the  lung  is  not  easy.  In  my 
case,  the  widespread  lesion,  with  little  or  no  sputum,  comfort 
during  quiet,  with  dyspnea  on  movement,  absence  of  tempera- 
ture, and  a  peculiar  feeling  to  the  palpating  fingers  which  was 
entirely  different  from  tuberculosis  caused  me  to  make  a  diag- 
nosis of  probable  new  growth  in  spite  of  the  absence  of  a  history 
of  cancer  in  some  other  portion  of  the  body.  Later,  tumor  cells 
were  found  in  the  sputum  and  the  case  was  proved  postmortem. 

In  the  secondary  metastatic  tumors  of  the  lung,  the  history 
of  a  previous  tumor  in  some  part  of  the  body  is  suggestive. 


CHAPTER  XXII. 

PROGNOSIS. 

Introductory  Remarks. — There  are  many  factors  which  must 
be  taken  into  account  in  arriving  at  a  prognosis,  each  one  of 
which  influences  the  chances  for  recovery,  to  a  greater  or  lesser 
degree. 

It  is  but  a  few  years  since  tuberculosis  was  considered  an 
incurable  disease.  Today,  however,  clinical  experience  warrants 
the  assertion  that  tuberculosis  is  not  only  curable,  but  that,  when 
treated  at  the  right  time,  and  in  the  proper  manner,  it  may  be 
overcome  and  the  patient  be  restored  to  health  in  a  very  large 
per  cent  of  cases.  Early  clinical  tuberculosis  when  properly 
treated,  should  have  a  mortality  no  greater  than  that  of  other 
common  infectious  diseases. 

The  hopeful  side  of  the  tuberculosis  problem  has  been  well 
stated  by  Eisner.1    In  speaking  of  chronic  tuberculosis,  he  says : 

"A  large  number  of  these  cases  are  curable,  many  become  la- 
tent; the  vital  fact  which  interests  us  in  considering  their  future 
is  that  they  can  only  be  saved  by  early  diagnosis  and  prompt  treat- 
ment. Put  in  the  resistance,  bring  the  condition  of  the  patient  to 
par  or  above,  and  the  disease,  if  it  is  in  its  incipiency,  will  be 
stayed  in  over  eighty  per  cent  of  all  cases,  while  twenty  per  cent 
of  all  forms  of  the  disease  are  saved.  To  wait  for  definite  physical 
signs  before  making  a  diagnosis  darkens  prognosis,  for  the  pa- 
tient's chances  are  reduced  thereby.  To  anticipate  the  final  de- 
velopment in  cases  which  are  strongly  suggestive,  adds  to  the 
patient's  chances.  Positive  physical  signs  are  never  early  evidence 
of  lung  infection;  they  mean  that  the  case  is  advanced." 

Age. — The  prognosis  differs  according  to  the  age  of  the  pa- 
tient. The  most  serious  age  period  for  tuberculosis,  all  things 
else  being  equal,  is  the  first  five  years  after  birth.  During  this 
period  the  patient  is  gradually  developing  a  specific  cellular  re- 
sistance, and,  until  such  time  as  this  has  been  attained,  the  or- 


aMonographic  Medicine,  D.  Appleton  &  Co.,  1916,  vol.  vi. 


CONSTITUTION  625 

ganism  is  not  capable  of  overcoming  large  quantities  of  tubercle 
bacilli;  consequently,  if  a  severe  infection  occurs  during  this 
period,  the  patient  has  little  chance  of  overcoming  it.  As  shown 
by  the  statistics  of  Hamburger,  quoted  in  Chapter  IV,  there  is 
practically  no  tendency  toward  healing  shown  in  patients  suf- 
fering from  tuberculosis  during  the  first  two  years  of  life ;  and  it 
is  only  after  the  fifth  or  sixth  year  that  the  child  begins  to  show 
an  increased  resistance.  From  that  time  on,  we  see  more  of  a 
tendency  for  the  disease  to  become  chronic.  By  the  time  the 
child  reaches  the  fifteenth  year  chronicity  is  manifested  in  one- 
half  of  the  cases;  and,  after  the  fifteenth  year,  chronicity  becomes 
more  and  more  common;  in  fact,  becomes  the  rule. 

Constitution. — While  we  have  learned  in  recent  years  that 
tuberculosis  is  not  an  inherited  disease,  yet  it  is  necessary  for 
the  clinician  to  take  into  consideration  the  constitution  which 
is  given  to  the  individual  at  birth.  While  environment  is  prob- 
ably a  much  greater  factor  in  the  development  of  a  child  than 
heredity,  yet  there  is  no  question  but  that  heredity  counts  for 
something.  The  inheritance  of  a  weakly  constitution  in  an 
individual  who  lives  in  a  poor  environment,  makes  the  worst  com- 
bination possible.  There  are  certain  people  who  seem  to  be 
born  with  deficient  nervous  and  physical  mechanisms.  Stiller 
has  called  attention  to  one  type,  asthenia  congenita  universalis. 
This  type,  he  believes,  is  born  with  nervous  and  physical  mechan- 
isms below  par,  even  though  the  asthenic  state  does  not  develop 
until  after  puberty.  Many  individuals  in  whom  a  weakly  consti- 
tution has  been  recognized  in  the  past,  do  not  inherit  this  consti- 
tution, but  develop  it  after  birth;  in  fact,  many  of  those  who 
are  physically  below  par,  and  who  are  suffering  from  so-called 
phtJiisicus  Jiabitus,  are  not  fit  subjects  for  infection,  as  is  usually 
expressed,  but  have  this  habitus  because  of  a  previous  infection. 
A  person  with  a  weakly  constitution,  naturally,  should  not  be  ex- 
pected to  have  as  much  resistance  to  disease  as  one  who  is  physi- 
cally and  nervously  more  fit;  at  the  same  time,  it  does  not  mean 
that  those  with  weakly  constitutions  must  be  given  up  as  hope- 
less, should  they  develop  tuberculosis. 

It  has  been  my  lot  to  treat  a  great  many  patients  with  poor 
physique,  who  had  developed  tuberculosis;  and,  in  case  the  in- 


626  PROGNOSIS 

fection  was  not  too  severe,  I  have  seen  excellent  results  obtained 
in  many  of  low  physical  and  nervons  vigor. 

Environment. — The  environment  in  which  the  patient  lives 
probably  has  more  to  do  with  prognosis  than  any  other  factor. 
This  temi  "environment"  means  so  much  that  it  comprises 
many  other  subjects  which  will  be  discussed  in  this  chapter.  I 
shall  discuss  environment,  however,  giving  to  it  a  limited  mean- 
ing. 

If  we  discuss  environment  in  connection  with  the  physical 
surroundings  of  the  patient  we  can  see  what  an  important  ele- 
ment it  is  in  prognosis.  It  further  includes  the  home  surround- 
ings, in  which  the  patient  lives,  as  well  as  his  social  and  economic 
status.  All  of  these  are  big  factors  in  determining  whether  or 
not  a  patient  with  tuberculosis  shall  get  well.  Environment  may 
be  helpful,  as  well  as  harmful.  If  a  patient  lives  in  a  stuffy 
room,  with  dead  air,  his  opportunity  for  recovery  is  not  as  good 
as  though  he  were  in  the  open  air.  If  he  is  surrounded  by  de- 
pressive circumstances,  and  depressive  conditions,  naturally,  it 
will  affect  prognosis  unfavorably.  If  the  members  of  his  family, 
and  the  friends  with  whom  he  lives,  are  cheerful  and  happy,  and 
determined  to  aid  him  in  carrying  out  his  routine,  his  chances 
for  recovery  are  far  greater  than  where  they  are  opposed  to  such 
a  routine.  It  is  possible  to  surround  a  patient  in  a  home  with 
cheerfulness  and  hope  and  give  him  encouragement,  and  so  ar- 
range the  physical  features  of  the  home  as  to  aid;  or  they  may 
be  arranged  so  as  to  have  the  contrary  effect.  Good  helpful  en- 
vironment adds  greatly  to  the  patient's  chances  of  cure;  while 
antagonistic  depressive  environment  makes  the  prognosis  much 
less  favorable. 

Economic  Status. — Tuberculosis  is  an  economic  disease.  It  is 
found  much  more  commonly  among  the  poor  than  among  the 
well-to-do,  but  exists  in  people  in  all  stations  of  life. 

Now  that  we  understand  tuberculosis  to  be  a  disease  which  is 
transmitted  through  ignorance  and  willfulness,  and,  since  infec- 
tion takes  place  largely  in  early  life,  and  clinical  tuberculosis 
develops  from  this  early  infection,  it  can  be  readily  understood 
that  the  economic  status  of  the  individual  is  a  big  factor  in  prog- 
nosis.    Ignorance  and  poverty  go  together,  yet  we  find  many 


ECONOMIC   STATUS  627 

worthy  intelligent  people  among  the  poor,  and  find  some  of  the 
grossest  ignorance  among  the  well-to-do.  Poverty  compels  peo- 
ple to  live  under  unsanitary  conditions.  It  is  necessarily  accom- 
panied by  an  inadequate  amount  of  food;  and  it  deprives  them 
of  many  of  the  healthful  pleasures  of  life.  Thus  it  acts  by  pro- 
ducing a  general  depression  of  the  physical  and  mental  capabil- 
ities of  the  patient. 

In  those  homes  of  the  poor,  in  which  overcrowding  occurs, 
there  is  great  danger  of  the  disease  being  communicated  to 
others;  and,  inasmuch  as  lowered  vitality  favors  infection,  this 
also  operates  to  make  transmission  easy.  Continued  living  under 
such  circumstances  makes  those  individuals  who  are  already  in- 
fected, more  prone  to  have  an  extension  or  recurrence  of  their 
disease. 

We  must  conceive  that  tuberculosis  is  a  disease  which,  taken 
into  the  body  early,  makes  more  or  less  effort  in  after  years  to 
extend  to  other  tissues  and  parts.  If  the  patient's  resisting 
powers  are  low  and  his  body  cells  are  impoverished,  they  are  not 
able  to  react  with  the  same  defensive  force  as  the  cells  of  those 
who  are  in  better  physical  and  nervous  condition;  consequently, 
the  economic  status  of  the  people  is  a  great  factor  in  providing 
for  their  material  wants,  hence  an  important  factor  in  the  prog- 
nosis of  tuberculosis.  It  is  also  important  from  the  standpoint 
of  treatment.  Unless  the  state  has  provided  adequate  care  for 
those  who  are  ill,  those  whose  economic  status  is  low  are  unable 
to  cope  with  the  disease.  Tuberculosis  is  a  long  drawn  out  dis- 
ease, the  individual  being  an  invalid  and  unable  to  work  for  a 
time  averaging  about  two  years.  During  all  this  time  he  must 
not  only  be  cared  for ;  but,  if  he  is  the  bread  winner,  the  remain- 
ing members  of  his  family  must  also  be  cared  for  or  suffer ;  con- 
sequently, if  poverty  is  present  at  the  beginning  of  the  disease, 
it  will  grow  worse  as  it  continues. 

The  state  and  the  municipality  have  both  begun  to  see  their 
duty  toward  the  tuberculous  poor,  and  we  now  have  provision 
made  for  many  of  those  who  are  ill.  Such  provision,  however, 
is  still  inadequate,  and  must  be  supplemented  by  private  philan- 
thropy to  as  great  an  extent  as  possible  until  full  provision  is 
made  for  all. 


628  PROGNOSIS 

While  the  financial  condition  of  the  patient  is  an  important 
factor,  yet  this  does  not  imply  that  the  prognosis  in  the  wealthy 
is  better  than  in  those  of  lesser  means.  On  the  contrary,  it  is 
often  rendered  unfavorable  by  other  conditions  which  come  with 
the  possession  of  large  means.  It  has  been  my  observation  that 
the  best  patients  to  treat  are  those  of  the  middle  class.  Here 
we  have  intelligence,  combined  with  enough  means  to  care  for 
the  patient,  yet  we  do  not  have  to  fight  the  ignorance  which  is 
so  common  among  the  very  poor,  and  the  willfulness  which  is  so 
common  among  the  very  wealthy. 

Mental  State. — The  mental  state  of  the  patient  is  very  im- 
portant in  prognosis.  Now  that  we  understand  the  action  of 
the  depressing  emotions  in  keeping  up  a  prolonged  stimulation  of 
the  sympathetic  nervous  system,  and,  through  it,  an  inhibition 
of  function  on  the  part  of  many  of  the  important  internal  vis- 
cera, we  can  offer  a  physiological  explanation  for  a  fact  which 
has  long  been  known;  namely,  that  prognosis  depends  very  much 
upon  the  mental  state  of  the  patient.  The  patient  will  often 
worry  about  some  symptom  which  is  comparatively  unimportant. 
He  will  complain  and  become  angry  over  the  failure  to  have 
some  little  whim  satisfied,  when  his  very  dissatisfaction  and 
anger  will  do  more  harm  than  the  conditions  about  which  he  was 
complaining.  From  a  prognostic  standpoint,  hope,  cheerfulness, 
and  contentment  are  very  important. 

THE  CHARACTER  OF  THE  LESION  IN  PULMONARY 
TUBERCULOSIS. 

Much  could  be  written  upon  the  subject  of  the  character  of  the 
lesion  in  tuberculosis,  but  I  will  attempt  to  discuss  it  briefly  from 
a  practical  standpoint. 

Miliary  Tuberculosis. — Miliary  tuberculosis  is  usually  spoken 
of  as  being  fatal.  This  is  not  true.  In  generalized  miliary  tuber- 
culosis this  is  true;  but,  in  all  cases  of  tuberculosis  that  are  at 
all  extensive,  we  have  areas  of  miliary  infection,  which  yield  to 
the  defensive  powers  of  the  patient.  Miliary  tuberculosis  must 
not  be  confused  with  acute  general  miliary  tuberculosis.  The 
former  refers  to  the  small  tubercles,  while  the  latter  refers  to  a 


FIBROID   TUBERCULOSIS  629 

dissemination  of  the  disease  more  or  less  generally  throughout 
the  body,  the  infecting  bacilli  coming  from  a  common  focus  and 
becoming  implanted  in  the  tissues  at  the  same  time.  The  former 
is  favorable  for  cure;  the  latter  practically  hopeless. 

Fibroid  Tuberculosis. — Now  that  we  have  studied  more  of  the 
history  of  our  infections  in  tuberculosis,  and  realize  that  they 
start  in  childhood,  and  gradually  extend  by  secondary  metastases, 
we  have  learned  that  infiltrations  are  often  present  for  years 
without  producing  open  active  tuberculosis;  but  we  are  further 
coming  to  learn  that  there  are  types  of  infection  which  are  com- 
paratively harmless  during  their  early  stage,  but  which  take 
upon  themselves  ulceration  and  become  serious  as  a  later  mani- 
festation. Not  infrequently  do  we  see  lungs  in  which  a  gradual 
extension  of  the  disease  from  one  focus  to  another  has  been  go- 
ing on  over  a  prolonged  period  of  time.  Such  patients,  as  a  rule, 
show  evidence  of  a  chronic  toxemia.  -They  have  a  deficient  nerve 
balance;  unstable  heart's  action;  suffer  from  stomach  disturb- 
ance, with  a  resultant  malnutrition;  and  show  a  disinclination 
and  inability  to  carry  on  work.  They  may  have  a  slight  rise  in 
temperature  at  times,  or  they  may  not.  Finally,  after  this  stage 
of  semi-invalidism  has  gone  on  for  a  period  of  time, — it  may  be 
a  few  years  or  it  may  be  many  years, — the  patient  is  surprised 
by  some  such  symptom  as  hemorrhage,  pleurisy,  repeated  at- 
tacks of  bronchitis,  and  probably  expectoration  which  shows 
bacilli. 

Did  we  recognize  this  form  of  tuberculosis  early,  nearly  every 
one  of  these  patients  could  get  well;  but,  as  long  as  we  delay 
our  diagnosis  until  the  more  active  symptoms  manifest  them- 
selves, just  so  long  will  we  fail  to  do  our  duty  by  these  patients 
by  treating  them  at  a  time  when  the  prognosis  is  favorable.  We 
should  bear  in  mind  that  chronic  fibroid  tuberculosis  has  as  its 
terminal  picture,  in  most  instances,  chronic  fibro-ulcerative  tuber- 
culosis ;  consequently  it  demands  early  recognition  and  early 
treatment  if  it  is  to  offer  a  favorable  prognosis. 

Chronic  Ulcerative  Tuberculosis. — This  type  of  tuberculosis  in 
a  pure  form  is  rarely,  if  ever,  found,  because  all  chronic  tubercu- 
losis must  be  accompanied  by  some  fibrosis.  What  I  refer  to, 
however,  is  the  type  of  tuberculosis  in  which  the  ulcerative  form 


630  PROGNOSIS 

predominates.  We  often  see  a  patient  who  has  had  a  previous 
infection  in  the  lung,  suddenly  manifest  acute  symptoms  with 
ulceration  and  cavity  formation,  and  bacillus  bearing  sputum. 
From  the  first  ulcerations,  bacilli  escape  and  form  metastases; 
and  repeated  metastases  follow  necrosis  and  caseation  of  other 
areas.  If  this  type  of  disease  manifests  a  tendency  to  heal,  it 
Mali  sooner  or  later  take  upon  itself  a  combination  of  the  ulcera- 
tive and  fibroid  form.  Areas  will  cease  becoming  necrotic  and 
the  stimulation  of  the  fixed  cells  will  result  in  the  increase  of 
fibrous  tissue  with  a  tendency  to  heal. 

Acute  Caseous  Tuberculosis. — This  is  the  type  of  tuberculosis 
that  we  often  see  where  there  is  a  large  area, — often  a  lobe,  or 
more  commonly,  a  portion  of  a  lobe,  in  which  the  disease  de- 
velops rapidly  going  on  to  necrosis.  The  infection  in  this  type 
of  disease  often  comes  from  plugging  a  bronchus  with  bacillus- 
bearing  sputum.  The  infection  is  virulent  because  of  the  fact 
that  a  great  many  bacilli  are  implanted  at  the  same  time,  and 
overcome  the  patient's  resisting  power.  The  entire  tubercu- 
lous area  is  in  the  same  degree  of  pathological  change.  This 
type  is  accompanied  by  a  severe  toxemia,  which  results  in  a 
breaking  down  of  the  patient's  defense;  consequently,  the  dis- 
ease usually  develops  rapidly. 

This  type  of  tuberculosis  sometimes  offers  a  favorable  prog- 
nosis. If  widespread,  however,  as  a  rule,  the  toxemia  is  so 
severe  that  it  proves  fatal.  I  have  often  seen  a  caseous  pneu- 
monia involving  an  entire  lobe  come  to  a  state  of  arrestment.  It 
did  this  by  practically  amputating  the  entire  area  of  infection. 
Necrosis  and  caseation  occurred  and  the  entire  mass  sloughed 
out,  leaving  an  empty  shell.  In  such  cases,  if  the  process  does 
not  last  too  long,  and  if  the  tissues  can  slough  out  within  a 
reasonable  time  before  the  patient's  vitality  is  undermined,  an 
arrestment  may  result.  If,  on  the  other  hand,  the  toxemia  con- 
tinues until  the  patient's  metabolism  is  seriously  interfered  with, 
but  one  result  can  be  expected, — a  fatal  termination. 

While  there  are  many  other  forms  of  pulmonary  tuberculosis 
that  might  be  mentioned,  yet  these  are  the  common  types  that 
are  met  with  in  every  day  practice.  From  the  prognostic  stand- 
point, the  small  lesion  is  most  favorable.     The  small  lesion  is 


TUBERCULOUS   COMPLICATIONS  631 

nearly  always  fibroid  in  character.  It  is  accompanied  by  little 
or  no  collateral  inflammation,  and  little  or  no  necrosis  and 
caseation.  It  is  much  easier  to  attain  a  favorable  result  in  the 
lesion  which  is  small  and  of  such  a  character  that  the  danger  of 
scattering  the  infection  is  comparatively  remote  than  in  the  ex- 
tensive active  one. 

TUBERCULOUS  COMPLICATIONS. 

Not  only  must  we  consider  the  type  of  the  pulmonary  disease, 
but  we  must  consider  the  complications  which  are  present.  It  is 
possible  to  have  a  primary  infection  of  almost  any  tissue  or  or- 
gan of  the  body,  as  I  have  discussed  in  the  chapters  dealing  with 
the  various  tuberculous  lesions ;  nevertheless,  nearly  all  infec- 
tions outside  of  the  lymphatic  tissues  are  metastatic  in  char- 
acter and  must  be  looked  upon  as  taking  place  after  an  in- 
fection has  already  existed  in  the  body,  and  after  the  cells 
have  taken  upon  themselves  the  property  of  producing  defensive 
substances  against  the  bacilli.  Nearly  all  such  lesions  heal 
or  become  quiescent  at  first,  because  the  number  of  bacilli  produc- 
ing them  is  small,  and  the  infiltration  is  not  extensive.  The 
prognosis,  therefore,  should  be  good,  unless  the  infection  is  local- 
ized in  tissue  of  such  a  character  as  to  produce  serious  or  fatal 
symptoms. 

Tuberculosis  of  the  Larynx. — Tuberculosis  of  the  larynx,  in 
my  experience,  has  always  been  secondary  to  an  infection  some- 
where else  in  the  body, — usually  the  lung.  The  likelihood  of  a 
primary  involvement  of  this  organ  is  extremely  remote.  The 
infection  is  usually  a  surface  infection,  taking  place  from  the 
bacillus-bearing  sputum,  as  it  comes  from  the  ulceration  in  the 
lung.  The  prognosis  of  tuberculosis  of  the  larynx  depends  both 
upon  the  character  of  the  lesion  in  the  lung  and  that  in  the 
larynx.  The  prognosis,  barring  those  cases  which  are  so  severe 
as  to  interfere  with  nutrition,  is  about  the  same  as  that  of  the 
accompanying  pulmonary  disease.  If  the  lung  is  actively  in- 
flamed and  undergoing  a  process  of  rapid  necrosis  and  caseation, 
there  is  little  chance  of  the  tuberculous  infection  in  the  larynx 
healing,  no  matter  how  slight  its  character.    On  the  other  hand, 


632  PROGNOSIS 

if  the  tuberculosis  in  the  lung  is  arrested,  or  only  moderately 
active,  even  severe  ulcerations  in  the  larynx  may  heal. 

If  we  speak  of  the  laryngeal  involvement  as  a  process  by  itself, 
it  may  be  said,  the  same  as  in  tuberculosis  of  the  lungs,  that  the 
prognosis  is  in  proportion  to  the  severity  of  the  lesion.  Slight 
infiltrations  will  nearly  always  heal  if  the  condition  of  the  pa- 
tient be  fairly  good  and  the  pulmonary  condition  be  not  too  ex- 
tensive nor  too  active;  moderately  advanced  lesions  will  heal 
in  a  very  large  percentage  of  cases  under  similar  circumstances; 
and  severe  lesions  will  heal  occasionally  if  the  lesion  is  located 
so  that  the  patient  can  maintain  his  nutrition. 

Tuberculosis  of  Intestines. — Tuberculosis  of  the  intestine  is 
generally  looked  upon  as  offering  an  unfavorable  prognosis. 
This  is  not  necessarily  true,  although  it  must  be  considered  a 
grave  complication.  A  limited  involvement  of  the  intestine  may 
be  present  for  a  prolonged  period  of  time  without  producing 
serious  symptoms,  or  without  seriously  interfering  with  the  nu- 
trition of  the  patient.  Under  such  circumstances  healing  occa- 
sionally occurs.  I  do  not  doubt  that  in  many  instances  infiltra- 
tions in  the  bowel  heal  without  their  presence  having  been 
suspected.  When  the  lesion  becomes  extensive,  however,  then 
digestion  and  assimilation  is  interfered  with  to  such  an  extent 
that  the  prognosis  is  grave. 

I  have  a  patient  under  my  care  at  the  present  time  who  has 
had  a  tuberculous  involvement  for  a  year  and  a  half  or  two 
years,  the  exact  time  I  do  not  know.  It  was  discovered  at  opera- 
tion eighteen  months  ago.  At  that  time  ulcerations  were  pres- 
ent from  the  pylorus  to  the  descending  colon.  This  patient  has 
never  had  a  diarrhea;  neither  has  she  suffered  markedly  with 
gas  pains.  She  has,  however,  had  difficulty  in  maintaining  her 
nutrition.     She  has  gradually  lost  weight  and  strength. 

One  of  the  serious  factors  in  tuberculosis  of  the  bowel,  from 
the  prognostic  standpoint  is  the  fact  that  opportunity  for  re- 
peated surface  infection  is  always  present,  and  even  though  the 
part  may  be  removed,  the  same  likelihood  of  recurrence  is  pres- 
ent as  existed  prior  to  the  operation. 

Pleurisy. — Pleurisy  often  causes  an  early  diagnosis  of  tuber- 
culosis to  be  made  and  in  this  way  causes  the  patient  to  secure 


TUBERCULOUS    COMPLICATIONS  633 

therapeutic  aid  at  a  time  when  the  prognosis  is  good.  Pleurisy 
itself  also  has  a  definite  influence  on  prognosis  at  times.  The 
average  pleural  adhesions  at  the  apex  probably  make  very  little 
difference,  as  far  as  the  patient  is  concerned,  except  as  they  cause 
intermittent  intercostal  pain  and  interfere  slightly  with  the  in- 
spiratory act;  but  a  pleurisy  with  effusion  at  the  base,  which 
fails  to  absorb,  and  results  in  a  general  fibrosis  involving  the 
lung,  proves  decidedly  unfavorable.  So,  at  times,  do  wide- 
spread adhesions.  Adhesions  extending  over  the  entire  lung  in- 
terfere greatly  with  the  inspiratory  act  and  in  this  way  favor 
splanchnic  congestion,  interfering  with  the  return  flow  of  blood 
to  the  heart.  The  general  venous  congestion  which  shows  it- 
self when  widespread  pleural  adhesions  are  present,  must  also 
interfere  with  nutrition  because  perfect  metabolism  depends  upon 
the  normal  rapidity  of  blood  flow. 

Pneumothorax. — Pneumothorax,  strictly  speaking,  is  not  a  tu- 
berculous complication,  yet  it  may  be  regarded  as  such  because 
of  the  fact  that  it  results  so  often  from  a  rupture  of  a  tubercle 
in  the  visceral  pleura.  Spontaneous  pneumothorax  is  often 
looked  upon  as  being  an  extremely  serious  complication  in  tuber- 
culosis. This  has  not  been  my  experience.  I  have  had  favorable 
experiences  following  its  appearance  more  often  than  otherwise. 
In  the  majority  of  cases  that  have  come  under  my  care,  the  pa- 
tient has  not  only  recovered  temporarily,  but  continued  to  make 
normal  improvement  after  the  complication  had  passed  away. 

Tuberculous  Meningitis. — Now  and  then  a  case  of  tuberculous 
meningitis  is  reported  as  having  healed.  There  is  no  reason 
why  this  should  not  be  true.  A  small  localized  tuberculous  in- 
volvement in  the  meninges  might  exist  without  producing  symp- 
toms of  sufficient  gravity  to  prove  serious.  In  case  the  patient's 
resisting  power  is  good  there  is  no  reason  why  healing  should 
not  occur  now  and  then  in  small  lesions.  When  the  disease  has 
become  extensive  and  widespread,  however,  healing  is  beyond 
question.  Meningitis  is  usually  accompanied  by  an  exudative 
process  which  produces  pressure,  resulting  in  deleterious  symp- 
toms, and,  sooner  or  later,  death. 

Bacilli. — The  presence  or  absence  of  bacilli  in  the  sputum 
greatly  influences  the  prognosis  in  tuberculosis.    Eecently,  a  sani- 


634  PROGNOSIS 

tarian  of  note,  when  giving  a  public  address,  made  a  statement 
which  gave  rise  to  the  inference  that  patients  with  tubercle 
bacilli  in  their  sputum  are  in  a  hopeless  stage  of  tuberculosis. 
What  he  probably  meant  was,  that  as  physicians,  we  have  lost 
time  and  reduced  the  favorableness  of  the  prognosis  very  ma- 
terially by  not  making  diagnoses  earlier ;  but,  it  would  be  wholly 
wrong  to  let  the  impression  go  out  that  patients  who  have  tu- 
bercle bacilli  in  their  sputum  cannot  get  well.  There  is  no  doubt 
of  the  difficulties  which  are  met  in  endeavoring  to  bring  about 
healing  in  patients  who  are  suffering  from  open  tuberculosis; 
but  a  large  per  cent  of  those  who  have  but  recently  entered  upon 
the  open  stage  of  the  disease,  with  tubercle  bacilli  in  their  sputum, 
can  get  well  if  given  proper  treatment.  The  difference  between 
the  closed  focus  and  open  tuberculosis,  however,  from  the  prog- 
nostic standpoint,  is  a  long  step.  The  prognosis  drops  very 
rapidly  after  ulceration  and  bacillus-bearing  sputum  appears. 
There  are  two  reasons  for  this:  One,  the  increased  danger  of 
infecting  other  areas  through  the  bronchi;  the  other,  the  in- 
creased difficulty  of  healing  a  broken-down  necrotic  area. 

The  form  of  the  tubercle  bacillus  has  also  been  spoken  of  as 
having  diagnostic  significance.  In  our  work  in  the  Pottenger 
Sanatorium,  after  making  careful  examinations  of  sputum  for 
many  years  with  reference  to  the  morphology  of  the  tubercle 
bacillus,  we  have  confirmed  the  idea  suggested  by  Sewall  many 
years  ago,  that  the  short  bacillus  accompanies  activity,  and  the 
long  bacillus  is  a  representative  of  chronicity.  This  does  not 
mean,  however,  that  patients  with  short  bacilli  in  their  sputum 
cannot  get  well.  We  often  notice  an  increase  in  the  relative 
numbers  of  short,  as  compared  with  long  bacilli,  even  in  patients 
whose  progress  is  favorable.  It  must  be  remembered  that  the 
lungs  of  patients  suffering  from  advanced  tuberculosis  represent 
many  different  areas  of  infection,  which  differ  in  age.  There 
are  recent  ulcerations,  ulcerations  moderately  old,  and  ulcera- 
tions which  have  existed  sometimes  for  months  and  years.  The 
more  recent  ones  probably  throw  off  a  preponderance  of  short 
bacilli,  and  the  chronic  ones  a  preponderance  of  long  bacilli; 
consequently,  we  must  expect  a  mixture  of  the  various  types; 
and,  when  we  recall  that  the  chronic  ulceration  had  to  go  through 


TUBERCULOUS   COMPLICATIONS  635 

the  acute  stage,  so  may  we  expect  these  acute  ulcerations  to  pass 
on  to  the  chronic  stage  and  produce  the  long  type  of  bacillus. 
For  further  discussion  of  this  subject  see  page  564. 

The  Tuberculin  Reaction. — Much  has  been  written  regarding 
the  prognostic  importance  of  the  reaction  to  tuberculin,  particu- 
larly the  cutaneous  and  conjunctival  reactions.  Wolff-Eisner,  dur- 
ing his  many  studies  of  the  tuberculin  reaction,  claimed  that  the 
patient  who  reacted  well  to  the  conjunctival  reaction  offered  a 
good  prognosis.  Others  have  claimed  that  a  marked  cutaneous 
reaction  is  prognostically  favorable.  This  question  cannot  be 
discussed  simply  as  a  matter  of  reaction  because  it  is  necessary 
to  take  so  many  other  things  into  consideration. 

I,  personally,  have  always  interpreted  a  good  local  reaction  at 
the  point  of  injection  as  giving  evidence  of  the  presence  of 
specific  defensive  substances.  I  have  noted  that  the  patients 
whom  I  have  treated  (I  usually  employ  an  emulsion)  usually 
show  an  increased  tendency  to  local  reaction  as  their  disease  im- 
proves. Some  patients,  however,  make  a  perfectly  satisfactory 
improvement  and  do  not  show  these  local  reactions. 

There  are  many  things  to  be  considered  in  interpreting  tuber- 
culin reactions.  Sometimes  the  tuberculin  is  absorbed  and  car- 
ried off  readily.  Under  such  circumstances  we  would  not  expect 
to  have  a  strong  local  reaction.  At  other  times,  it  will  remain 
in  the  tissues  and  meet  the  specific  enzymes  which  are  prepared 
for  its  destruction,  producing  a  local  reaction,  which  is  more  or 
less  marked.  If  the  tuberculin  reaction  is  an  antigen-antibody 
reaction,  whether  it  be  local,  or  focal,  then  it  must  be  taken  as 
evidence  of  the  presence  of  a  specific  defense.  It  must  not  be 
considered,  however,  that  the  patient  who  shows  this  specific  de- 
fense will  necessarily  get  well  of  his  tuberculosis.  This  depends 
very  much  upon  the  future  course  of  the  disease,  as  well  as  upon 
the  way  the  case  is  handled.  Such  defense  may  change  from 
day  to  day,  from  week  to  week,  or  from  month  to  month;  con- 
sequently, it  is  very  difficult  to  discuss  this  question  as  an  ab- 
stract proposition.  It  must  be  considered  only  at  the  time  of  its 
exhibition,  and  must  be  expected  to  change  as  the  disease  pro- 
gresses. 


636  PROGNOSIS 

NON-TUBERCULOUS  COMPLICATIONS. 

Non-tuberculous  complications  may  arise  on  the  part  of  any 
organ  or  structure.  The  ones  which  require  particular  con- 
sideration, however,  are  those  which  confine  themselves  to  the 
four  great  systems  of  the  body,  the  nervous,  respiratory,  circula- 
tory, and  digestive. 

Nervous  System. — On  the  part  of  the  nervous  system  we  have 
numerous  complications  which  bear  upon  prognosis.  Nearly  all 
patients  who  suffer  from  tuberculous  toxemia  have  disturbances 
on  the  part  of  the  cells  of  the  central  nervous  system.  This  re- 
sults in  more  or  less  depression  of  nerve  tone.  Neurasthenia  is 
a  very  common  complication  of  tuberculosis;  in  fact,  nearly  all 
patients  have  it  to  some  degree.  It  influences  prognosis  to  the 
extent  that  the  neurasthenic  symptoms  are  permitted  to  inter- 
fere with  the  patient's  metabolic  activity.  A  neurasthenia  of 
mild  degree  does  not  seem  to  have  a  particularly  antagonistic  ef- 
fect; while,  in  some  cases,  a  severe  degree  may  have  an  influence 
in  making  the  prognosis  unfavorable  secondary  only  to  the  tu- 
berculous process  itself.  All  of  the  depressive  nervous  states 
produce  a  general  inhibition  of  the  functions  of  the  internal  vis- 
cera and  in  this  way  influence  prognosis  unfavorably. 

Not  only  do  we  have  a  general  loss  of  nerve  tone  designated 
as  neurasthenia,  but  we  have  an  actual  degeneration  of  nerve 
cells  as  a  result  of  the  tuberculous  toxemia.  This  is  sometimes 
sufficiently  extensive  to  produce  definite  organic  changes  in  the 
cells  of  the  central  nervous  system.  This  is  not  infrequently 
found  postmortem  in  subjects  who  have  had  a  prolonged 
toxemia. 

Aside  from  these  disturbances  we  have  the  effect  of  the  tuber- 
cle toxins  influencing  the  vegetative  nervous  system  and  pro- 
ducing changes  in  the  function  of  the  internal  viscera.  Inas- 
much as  the  nervous  system  largely  controls  cellular  activity, 
being  supplemented  so  far  as  we  know,  only  by  the  chemical  con- 
trol which  comes  from  the  various  internal  secretions,  we  can 
see  how  important  a  factor  in  prognosis  the  nervous  system  be- 
comes. 

The  Respiratory  System. — In  our  discussion  we  are  speaking 


NON-TUBERCULOUS   COMPLICATIONS  637 

mainly  of  pulmonary  tuberculosis.  Aside  from  the  lesion  in  the 
lung  or  larynx,  should  there  be  a  complication  on  the  part  of 
that  organ,  we  have  other  disturbances  in  the  respiratory  tract 
of  a  non-tuberculous  nature  which  affect  prognosis.  We  might 
mention  the  bronchitis  which  is  often  present,  and  the  malforma- 
tions of  the  upper  air  passages,  as  well  as  the  acute  infections, 
such  as  influenza  and  pneumonia,  which  commonly  occur  during 
the  process  of  the  disease.  All  of  these  affect  the  prognosis  to  a 
certain  extent. 

There  is  considerable  discussion  whether  or  not  the  patient 
should  be  operated  upon  for  conditions  which  interfere  with 
normal  nasal  respiration,  during  the  time  that  he  is  suffering 
from  active  tuberculosis.  Personally,  I  have  always  avoided 
operations  during  active  disease,  and  feel  that  it  is  better  to 
spare  the  patient  the  lowering  of  vitality  which  might  follow  the 
operation.  The  after-effect,  however,  should  normal  respiration 
be  restored,  might  overcome  any  deleterious  influences  of  the 
operation  itself.  I  would  not  counsel  operation,  however,  during 
periods  of  activity,  but  confine  it  to  the  times  when  the  disease 
is  quiescent. 

An  attack  of  influenza  superimposed  upon  tuberculosis  is  of- 
ten disastrous.  In  many  instances,  the  death  of  the  patient 
can  be  traced  to  a  severe  attack  of  this  disease.  Pneumonia 
also  oftentimes  proves  serious  for  the  tuberculous  patient;  at 
the  same  time,  I  have  seen  patients  with  a  widespread  tubercu- 
losis go  through  attacks  of  influenza  and  pneumonia  without 
apparent  harm  resulting. 

The  Digestive  System. — The  non-tuberculous  complications  on 
the  part  of  the  digestive  system  have  a  very  important  bear- 
ing upon  the  prognosis  in  tuberculosis.  Good  nutrition  is  es- 
sential to  cure.  The  tuberculous  patient  is  particularly  prone 
to  have  disturbances  on  the  part  of  the  gastrointestinal  tract, 
as  described  in  Chapter  X.  The  outcome  of  the  case  will  often 
depend  upon  the  success  with  which  these  complications  are 
handled.  Sometimes  what  appears  to  be  a  very  serious  inter- 
ference with  digestion  may  be  overcome  by  proper  treatment  and 
in  this  way  an  unfavorable  prognosis  be  averted. 

The  clinician  should  always  bear  in  mind  the  influences  which 


638  PROGNOSIS 

are  operating  to  interfere  with  the  function  of  the  gastroin- 
testinal tract.  Toxemia  always  tends  to  decrease  the  gastro- 
intestinal secretions,  as  well  as  interfere  with  the  motor  func- 
tion of  the  stomach  and  gut;  consequently,  toxemia  should  be 
relieved  as  quickly  as  possible.  Depression  has  the  same  effect 
upon  the  gastrointestinal  tract.  This  should  be  relieved  by  put- 
ting the  patient  in  the  proper  frame  of  mind.  There  are  reflex 
symptoms  on  the  part  of  the  stomach  and  intestines  which  re- 
sult from  the  inflammation  in  the  lung.  These  may  have  a 
tendency  to  cause  a  hyper-  or  hypo-secretion  of  either  the  stomach 
or  intestinal  glands.  They  may  also  have  a  tendency  to  increase 
or  decrease  motility  in  both  the  stomach  and  intestines.  By 
careful  analysis,  the  exact  condition  may  be  arrived  at  and  the 
disturbance  be  corrected.  While  the  tuberculous  patient  may 
have  gastric  ulcer,  duodenal  ulcer,  colitis,  appendicitis,  or  any 
other  complication  which  affects  the  gastrointestinal  canal,  yet 
the  majority  of  disturbances  on  the  part  of  the  digestive  tract 
are  of  a  functional  nature  and  come  through  disturbed  equi- 
librium on  the  part  of  the  vegetative  nervous  system. 

The  Circulatory  System  is  greatly  disturbed  in  tuberculosis, 
as  mentioned  in  Chapter  IX.  A  deficient  inspiratory  act  inter- 
feres with  the  normal  balance  between  the  arterial  and  venous 
system,  causing  a  storing  up  of  blood  in  the  veins,  particularly  in 
those  of  the  splanchnic  area,  and  a  relative  decrease  in  the 
amount  contained  in  the  arteries.  Because  of  the  disease  in  the 
lung,  many  vessels  are  obliterated,  and  the  right  heart  finds  it- 
self compelled  to  work  against  an  ever  increasing  pressure.  As 
a  result  of  this,  hypertrophy  of  the  right  ventricle  eventually 
takes  place.  As  a  result  of  toxemia  and  malnutrition,  the  en- 
tire body  cells  degenerate  as  the  disease  progresses.  The  heart 
muscle  itself  becomes  less  able  to  do  its  work  and  atrophies. 

The  final  result  obtained  in  tuberculosis  depends  largely  upon 
the  integrity  of  the  heart.  In  those  cases  where  an  arrestment 
of  the  disease  has  been  obtained,  which  is  accompanied  by  wide- 
spread fibrosis,  the  patient,  as  a  rule,  lives  as  long  as  the  heart 
will  stand  the  strain.  The  patient  with  an  advanced  destructive 
lesion  is,  as  a  rule,  living  on  the  reserve  energy  of  the  heart; 
consequently,  it  is  unable  to  measure  up  to  increased  demands 


NON-TUBERCULOUS   COMPLICATIONS  639 

made  upon  it.  The  prognosis  in  tuberculosis  depends  very  much 
upon  the  heart  muscle  and  the  proper  movement  of  the  blood; 
for  upon  these  depend  the  ultimate  metabolic  activities  of  the 
body. 

Urine. — The  urine  during  tuberculosis  shows  several  important 
variations  from  the  normal.  If  the  kidney  is  involved  in  the 
tuberculous  process,  we  are  apt  to  have  at  first  a  polyuria;  and  if 
the  calyx  is  involved,  this  is  usually  followed  by  pus,  and  blood 
appearing  later.  Where  an  amyloid  degeneration  of  the  kidney 
takes  place  it  is  not  uncommon  to  find  albumin.  Amyloid  de- 
generation is  a  disease  which  affects  the  blood  vessels  and  is 
usually  progressive.  There  may  at  first  be  a  small  area  involved 
which  permits  of  the  escape  of  albumin  into  the  urine.  As  the 
process  extends,  the  blood  vessels  involved  become  destroyed  and 
the  urine  may  lose  all  traces  of  albumin  for  a  time.  It  may  be 
free  over  a  prolonged  period  until  the  process,  becoming  more 
extensive,  causes  a  continuous  albuminuria.  This  being  a  waxy 
degeneration  of  the  blood  vessels,  and  usually  being  associated 
with  the  same  process  in  other  internal  viscera,  usually  offers  a 
bad  prognosis.  It  means  a  progressive  pathology  which  will, 
sooner  or  later,  lead  to  the  death  of  the  patient. 

The  Diazo  and  Urochromogen  Reactions. — These  reactions  fre- 
quently make  their  appearance  in  the  urine,  particularly  in  ad- 
vanced patients,  who  are  progressively  losing  ground.  These  re- 
actions, if  continuous  over  several  months,  as  a  rule,  suggest  a 
bad  prognosis.  Tuberculous  patients  often,  however,  will  have 
these  reactions  appear  during  an  acute  illness.  Under  such  con- 
ditions they  disappear  as  soon  as  the  acute  illness  is  over,  and 
are  not  prognostically  bad.  When  these  reactions  come,  how- 
ever, and  persist  for  several  months,  the  chances  of  the  patient's 
body  cells  ever  being  able  to  carry  on  their  normal  physiological 
function  again  is  highly  improbable.    (See  Chapter  XX,  page  569.) 

Blood  in  Tuberculosis. — The  condition  of  the  blood  in  tubercu- 
losis has  prognostic  significance.  It  is  self-evident  that  the  blood 
which  is  nearest  normal  in  its  constituent  parts,  functionates  the 
most  perfectly.  Inasmuch  as  the  blood  is  the  carrier  of  oxygen 
and  food  to  the  cells,  and  of  the  broken-down  products  to  the  ex- 
cretory organs,  the  necessity  of  preserving  its  normal  carrying 


640  PROGNOSIS 

power  is  self-evident.  This  is  particularly  true  in  tuberculosis, 
because  we  have  so  many  other  factors  which  also  go  to  interfere 
with  metabolic  activity.  The  circulatory  system  is  disturbed  so 
that  the  blood  does  not  circulate  freely  and  normally.  We  have 
interference  with  the  normal  oxygenation  of  the  blood.  We  also 
have  degeneration  in  the  various  cells  of  the  body  so  that  they 
are  not  able  to  functionate  normally,  even  though  the  blood  is 
able  to  supply  their  needs  and  relieve  them  of  their  effete  prod- 
ucts with  its  usual  efficiency.  From  this  it  will  be  seen  that 
the  condition  of  the  blood  has  a  very  important  prognostic  bear- 
ing in  tuberculosis,  and  it  should  be  our  endeavor  to  keep  its 
standard  as  high  as  possible. 

Pregnancy. — Pregnancy  influences  prognosis  in  clinical  tuber- 
culosis unfavorably.  Many  years  ago  it  was  noted  that  certain 
patients  suffering  from  clinical  tuberculosis  improved  during  the 
pregnant  term,  and  it  was  not  uncommon  for  physicians  to  ad- 
vise tuberculous  women  to  become  pregnant  as  a  therapeutic 
measure.  This  observation,  however,  like  many  others  in  med- 
icine, was  not  complete.  While  some  women  improved  during 
pregnancy,  many  became  more  seriously  ill  and  many  of  those 
who  showed  improvement  during  the  term  lost  all  that  they  had 
gained  and  suffered  from  a  more  active  disease  after  delivery. 
I  look  upon  pregnancy  as  being  one  of  the  most  serious  compli- 
cations in  active  tuberculosis.  The  extra  burden  upon  the  pa- 
tient during  the  period  of  gestation  usually  results  in  reducing 
her  vitality  and  permitting  the  disease  to  extend.  Then,  the 
strain  of  delivery,  and  the  extra  cares  and  burdens  which  re- 
sult in  the  care  of  the  child,  are  almost  sure  to  bring  about  in- 
creased activity  of  the  disease. 

The  question  of  whether  a  woman  who  has  suffered  from  ac- 
tive tuberculosis  may  safely  bear  a  child  is  one  that  must  be  care- 
fully considered.  This  question  cannot  be  answered  in  the  ab- 
stract, but  conditions  in  each  individual  case  must  be  carefully 
considered.  A  woman  of  the  middle,  or  well-to-do  classes,  who 
could  be  properly  cared  for  during  gestation,  delivery,  and  af- 
ter delivery,  would  be  running  less  risk  than  the  poor  woman 
who  could  not  have  such  care.  As  a  rule,  I  advise  tuberculous 
women  who  have  suffered  from  an  early  active  tuberculosis,  that 


CHARACTER  OF   TREATMENT  641 

it  is  unwise  to  bear  children  until  they  have  been  well  for  a 
period  of  at  least  two  years.  If  they  have  not  shown  any  active 
symptoms  for  two  years'  time,  and,  providing  they  can  have 
the  proper  care  and  attention,  I  then  feel  that  the  danger  of  child 
bearing  is  comparatively  slight.  The  burden  of  childbirth  is 
often  less  than  the  mental  effect  of  feeling  that  they  are  not  able 
to  bear  children.  The  danger  of  lighting  up  a  process  which  has 
been  quiescent  is  relatively  greater  in  proportion  to  the  severity 
of  the  disease.  Many  advanced  and  far  advanced  cases,  under 
no  circumstances,  should  be  advised  or  permitted  to  undergo  the 
strain  of  childbirth. 

The  question  arises,  should  a  woman  suffering  from  active 
tuberculosis,  or  one  who  has  recently  secured  an  arrestment,  be- 
come pregnant,  what  is  the  proper  course  for  her  safety?  This 
is  another  question  that  must  be  considered  individually.  In 
many  cases  it  is  wiser  to  interrupt  the  course  of  pregnancy,  if 
it  is  diagnosed  early.  Other  cases  may  be  properly  cared  for 
and  the  pregnancy  be  allowed  to  continue.  Under  all  such  cir- 
cumstances, however,  if  the  pregnancy  is  allowed  to  continue 
the  patient  must  receive  careful  attention,  and  must  not  be  al- 
lowed to  go  through  a  long  strenuous  delivery,  and  must  be  given 
every  care  possible  following  the  birth  of  the  child. 

PROGNOSIS  DEPENDS  ON  CHARACTER  OF 
TREATMENT. 

Prognosis  From  the  Standpoint  of  the  Physician. — The  prog- 
nosis in  a  given  case  of  tuberculosis  depends  very  much  upon 
the  physician  who  treats  the  case.  This  is  a  disease  which  has 
a  tendency  to  heal;  but,  at  the  same  time,  in  a  large  majority 
of  cases,  after  it  becomes  a  clinical  entity,  it  has  a  tendency  to 
grow  progressively  worse.  Whether  or  not  it  shall  be  checked 
in  its  course  of  advancement  depends  very  much  upon  the  in- 
telligence with  which  the  treatment  is  directed.  All  things  else 
being  equal,  the  man  who  understands  tuberculosis  best  should 
be  able  to  handle  the  case  most  successfully.  In  practice,  how- 
ever, it  does  not  always  work  out  in  this  way  because  we  are  not 
only  dealing  with  a  disease,  but  we  are  dealing  with  an  individ- 


642  PROGNOSIS 

ual ;  so,  the  prognosis  in  tuberculosis,  in  a  given  case  depends  not 
only  upon  the  physician's  knowledge  of  the  disease,  but  upon  his 
ability  to  successfully  inspire  the  patient  to  a  whole-hearted  co- 
operation. The  physician's  responsibility  in  tuberculosis  is 
greater  than  in  almost  any  other  ordinary  disease  because,  at 
best,  the  disease  is  one  which  will  extend  over  many  months, — 
often  several  years, — and,  during  all  this  time  it  is  the  duty  of 
the  physician  to  guide  the  patient  in  such  a  manner  that  he  is 
able  to  preserve  his  resisting  power  and  keep  his  defensive  forces 
acting  to  best  advantage.  The  prognosis  will  usually  depend 
upon  the  success  with  which  the  physician  is  able  to  accomplish 
this  end. 

Cooperation  of  the  Patient. — No  matter  how  intelligent  the 
physician  may  be,  and  no  matter  how  comprehensive  and  satis- 
factory his  plan  of  treatment,  unless  the  patient  gives  a  whole- 
hearted cooperation  his  chances  of  recovery  from  active  tuber- 
culosis are  not  good.  A  patient  may  throw  away  all  chances 
of  recovery  by  some  foolish  act;  or,  he  may  turn  an  apparently 
hopeless  prognosis  into  a  favorable  one  by  faithful  cooperation. 

Earliness  of  Diagnosis  and  Treatment. — The  prognosis  of  tu- 
berculosis depends  largely  upon  the  earliness  of  diagnosis  and 
the  time  when  proper  treatment  is  instituted.  The  pathology  of 
this  disease  is  such  that  it  becomes  more  complex  as  the  disease 
advances.  In  the  beginning,  when  the  lesion  is  small,  it  is  not 
such  a  difficult  thing  to  prevent  the  disease  from  spreading,  and 
keep  the  patient  in  the  proper  environment,  both  mental  and 
physical,  until  his  lesion  is  healed.  While  the  lesion  is  small 
there  is  not  the  same  opportunity  for  bacilli  to  escape  and  form 
metastases  that  there  is  later,  for  the  foci  are  smaller  and  fewer 
in  numbers  than  when  the  disease  is  extensive.  Bacilli  escape 
into  adjacent  tissues  or  into  the  blood  stream  during  the  periods 
when  the  foci  of  infection  have  become  necrotic,  caseate  and 
break  down.  The  greater  the  number  of  caseating  tubercles, 
the  greater  the  danger  of  such  escape  of  tubercle  bacilli,  and  the 
greater  the  demands  upon  the  body  to  keep  infection  from  oc- 
curring. Thus,  it  can  be  seen  that  a  small  lesion  does  not  tax 
the  organism's  defensive  powers  nearly  as  much  as  a  widespread 
lesion.    No  patient  ever  dies  from  the  original  focus,  but  through 


CHARACTER   OF   TREATMENT  643 

extensions  and  repeated  extensions.  It  is  to  the  prevention  of 
these  metastases,  and  secondary  metastases  that  much  of  our 
therapeutic  endeavor  is  directed.  It  is  important  to  heal  the 
lesion  which  already  exists,  and  to  that  end  we  endeavor  to 
raise  the  resisting  power  of  the  patient  to  the  highest  point  pos- 
sible, and  to  stimulate  his  foci  of  infection,  by  specific  focal 
reactions,  produced  either  by  tubercle  protein  from  his  own  tu- 
bercles, or  by  the  tubercle  protein  introduced  from  without. 

It  is  not  difficult  to  see  the  great  importance  of  treating  the 
lesion  while  it  is  small.  In  this,  tuberculosis  is  no  exception  to 
other  diseases.  It  is  far  better  to  repair  a  small  damage  than  to 
wait  until  it  grows.    This  is  a  good  rule  in  all  lines  of  endeavor. 

Early  diagnosis,  with  proper  treatment,  in  intelligent  patients, 
should  bring  about  an  arrestment  in  at  least  90  per  cent  of  cases. 
After  the  disease  has  extended,  however,  and  the  early  clinical 
tuberculosis  has  passed  on  into  the  moderately  advanced  stage, 
the  prognosis  has  been  reduced  from  90  per  cent  to  50  or  60  per 
cent.  The  time  required  for  this  decline  in  prognosis  to  occur 
may  be  short  or  it  may  be  long.  Very  often  we  see  an  early 
lesion  change  to  one  of  moderately  advanced  activity  within  a 
period  of  a  few  weeks. 

Time  is  the  essential  factor  in  tuberculosis.  The  time  of  the 
diagnosis,  the  time  when  treatment  is  begun,  and  the  length  of 
the  time  that  the  treatment  is  carried  out  are  factors  of  the 
greatest  importance. 

Advanced  tuberculosis,  while  not  hopeless,  as  was  formerly 
thought,  proves  to  be  very  difficult  to  control.  If  we  take  the 
ordinary  advanced  cases  of  tuberculosis  as  they  come  to  us,  the 
chances  of  bringing  about  a  healing  are  not  very  good.  We 
can  produce  a  healing,  under  ideal  conditions,  in  about  10  per 
cent  and  an  arrestment  in  about  30  per  cent  more,  if  we  include 
both  active  and  quiescent  cases  that  come  under  our  care.  If  we 
exercise  care  in  choosing  cases,  and  take  only  those  which  are 
more  hopeful,  we  can  bring  about  an  arrestment  in  a  very  much 
larger  percentage.  On  the  other  hand,  if  we  confine  our  endeav- 
ors to  those  who  are  suffering  from  active  advanced  disease,  with 
more  or  less  constant  toxemia,  the  percentage  will  be  greatly  re- 
duced. 


644  PROGNOSIS 

If  the  medical  profession  could  only  learn  the  importance  of 
early  diagnosis  and  the  immediate  treatment  of  tuberculosis,  it 
would  not  take  long  to  satisfy  the  most  skeptical  that  tubercu- 
losis is  a  curable  disease  even  with  our  present  indirect  methods 
of  treatment.  If,  on  the  other  hand,  we  are  to  continue  to 
spend  our  efforts  trying  to  repair  lungs  which  have  been  de- 
stroyed by  the  tuberculous  process,  and  continue  our  attempts 
to  restore  the  organism  to  a  condition  of  efficiency,  after  this 
disease  has  become  widespread,  both  laymen  and  physicians  will 
continue  to  feel  pessimistic  regarding  its  prognosis. 

Character  of  Treatment. — The  prognosis  depends  very  much 
upon  the  character  of  the  treatment.  Some  patients  get  well 
without  undergoing  any  definite  course  of  treatment,  even  with- 
out knowing  that  they  have  had  clinical  tuberculosis.  Most 
patients,  however,  when  the  active  disease  has  made  its  appear- 
ance, require  some  form  of  active  assistance  if  they  are  to  re- 
cover their  health.  Tuberculosis  requires  a  carefully  planned 
therapy.  This  is  particularly  true  because  we  have  no  definite, 
direct  method  of  attacking  it.  Until  we  can  find  some  specific 
remedy,  like  quinine  in  malaria,  or  salvarsan  and  mercury  in 
syphilis,  which  will  directly  attack  the  tubercle  bacillus  and 
produce  its  destruction,  we  must  work  on  in  an  indirect  way.  It 
is  necessary  at  the  present  time,  to  deal  largely  with  the  pa- 
tient's resisting  power.  While  this  is  an  indefinite  and  uncer- 
tain quantity,  yet,  with  our  recent  advances  in  knowledge,  it  is 
becoming  a  more  tangible  asset.  We  must  build  up  his  nutri- 
tion; keep  his  metabolic  activities  at  the  highest  point  possible; 
aim  to  preserve  his  nervous  equilibrium;  a  healthy  gastroin- 
testinal activity,  and  an  efficient  circulatory  balance.  This  can 
only  be  done  by  carefully  studying  the  patient  as  an  individual 
and  suiting  the  various  remedies  and  measures  which  are  at  our 
command  to  his  needs. 

The  only  remedy  we  have,  which  has  any  specific  action,  is 
that  derived  from  the  tubercle  bacillus  itself.  Preparations  made 
from  the  bacillus  are  specific  in  that  they  produce  protective  sub- 
stances against  those  portions  of  the  bacillus  contained  within 
them  and  in  that  they  react  when  they  come  in  contact  with  the 
specific  proteolytic  enzymes  which  the  body  cells  are  stimulated 


CHARACTER   OF    TREATMENT  645 

to  produce;  and  also  in  that  such  a  reaction,  if  it  occurs  in  and 
near  the  focus  of  infection,  stimulates  the  production  of  fibrosis 
and  healing. 

The  utilization  of  these  remedial  measures  for  the  best  in- 
terests of  the  patient  is  not  easy.  Many  of  them  seem  so  simple 
that  this  fact  alone  defeats  their  proper  employment. 

I  am  a  firm  believer  in  the  intensive  treatment  of  tuberculosis. 
Success  depends  upon  an  intimate  relationship  between  the  pa- 
tient and  physician  and  their  thorough  cooperation.  This  asso- 
ciation must  continue  over  a  prolonged  period  of  time;  and  the 
various  helpful  measures  must  be  adapted  to  the  patient's  par- 
ticular needs  as  they  change  from  time  to  time.  Such  treatment, 
when  carried  out  with  a  whole-hearted  cooperation  on  the  part 
of  the  patient,  makes  the  prognosis  in  tuberculosis  quite  favor- 
able. It  has  been  able  to  produce  an  arrestment  in  more  than 
90  per  cent  of  early  clinical  tuberculosis;  more  than  60  per  cent 
of  moderately  advanced  cases ;  and  more  than  30  per  cent  of  far 
advanced  cases.  The  let-alone  policy,  which  is  carried  out  far 
too  commonly,  will  reduce  the  percentages  above  mentioned,  by 
50  per  cent.  It  is  far  more  sensible  to  let  a  patient  carry  out  a 
let-alone  policy  with  typhoid  fever,  pneumonia,  scarlet  fever, 
and  other  acute  infections,  which  run  a  short  course,  than  it  is 
to  carry  out  such  a  policy  with  tuberculosis.  The  results  would 
be  no  more  disastrous  than  they  have  been,  and  still  are,  in  tu- 
berculosis, when  such  a  course  is  followed.  In  this  long  drawn- 
out  disease,  which  depends  so  much  for  favorable  results  upon 
a  prolonged  and  hearty  cooperation,  close  medical  supervision 
with  an  intensive  routine  is  an  important  factor  in  prognosis. 
Sanatorium  Versus  Home  Treatment. — When  the  diagnosis  of 
tuberculosis  is  made  the  most  important  question  to  decide  is 
whether  the  patient  is  to  be  treated  in  the  home  or  in  some  sana- 
torium. From  the  standpoint  of  prognosis,  there  is  no  question 
as  to  which  course  should  be  pursued.  From  the  standpoint  of 
expediency,  however,  at  times,  it  may  be  necessary  to  follow  a 
course  which  offers  less  chances  of  cure.  All  else  being  equal, 
and  granting  that  the  patient  is  being  treated  by  a  physician 
with  equal  skill,  whether  it  is  in  the  home  or  in  the  institution, 
and  that  the  institution  is  run  in  such  a  manner  as  to  give  the 


646  PROGNOSIS 

patient  the  benefits  which  such  an  institution  should  provide, 
there  is  no  comparison  in  the  two  methods  from  the  standpoint 
of  prognosis. 

A  properly  conducted  sanatorium  furnishes  an  ideal  place  for 
the  application  of  the  measures  which  are  best  and  most  useful 
in  the  treatment  of  tuberculosis.  It  removes  the  patient  from 
the  home  with  its  cares  and  worries;  relieves  him  from  contact 
with  business  and  its  troublesome  details;  and  places  him  in  an 
atmosphere  of  helpfulness  and  hopefulness,  where  he  has  an  op- 
portunity to  associate  intimately  with  trained  physicians  and 
attendants,  all  of  which  has  a  tendency  to  improve  his  chances 
of  cure. 

In  the  home,  on  the  other  hand,  the  difficulties  are  many,  and 
oftentimes  unsurmountable.  Home  cares;  home  worries;  a  fail- 
ure to  keep  up  the  proper  program;  the  attempt  to  make  the 
home,  which  was  intended  for  the  well,  a  place  for  the  sick,  while 
it,  at  the  same  time,  is  being  inhabited  by  those  who  are  well; 
and  the  association  with  those  who  are  interested  and  engaged 
in  the  usual  activities  of  life,  make  it  almost  impossible  for  the 
patient  to  keep  up  a  cooperation  sufficiently  long  for  the  disease 
to  become  arrested,  or  healed.  When  I  have  placed  my  patient 
in  the  sanatorium,  I  feel  that  his  chances  of  recovery  have  in- 
creased from  25  to  50  per  cent  (See  Volume  II,  Chapters  XL VII 
and  XLVIII.) 

Open  Air. — Open  air  as  a  curative  measure  in  tuberculosis  is 
universally  recognized,  and  rightly  so;  because  there  is  no  other 
single  factor,  which  is  so  generally  applicable  and  which  is  cap- 
able of  giving  the  patient  equal  aid.  Patients  can  get  well  of  tu- 
berculosis without  being  treated  in  the  open;  but,  when  we 
realize  that  the  great  value  in  the  air  is  the  physical  effect  which 
it  exerts  upon  the  body,  the  value  of  treating  a  patient  in  the 
open  air,  as  compared  with  treating  him  in  rooms,  particularly  in 
closed  rooms,  is  self-evident. 

It  is  desirable  that  those  who  are  treating  tuberculosis  should 
know  the  limitations  of  open  air  therapy,  and  realize  that  it  is 
only  one  of  many  measures  for  the  improvement  of  the  patient's 
general  resisting  power;  at  the  same  time,  they  should  fully 
realize  that  its  intelligent  application  materially  increases  the 


CHARACTER   OF   TREATMENT  647 

patient's  chances  of  cure.  When  weather  and  climatic  condi- 
tions are  favorable,  open  air  should  always  be  employed.  While 
it  is  possible  to  treat  patients  under  conditions  where  the  full 
benefit  of  open  air  cannot  be  satisfactorily  obtained,  it  is  all 
the  more  necessary  under  such  circumstances  to  bring  to  the  aid 
of  the  patient  other  measures  which  influence  metabolism,  such 
as  psychotherapy,  hydrotherapy,  good  food,  and  rest.  Open  air, 
as  I  have  described  more  fully  in  Volume  II,  Chapter  XXXVI,  im- 
proves the  nutrition  of  the  skin,  stimulates  the  superficial  nerve 
endings,  and,  through  them,  influences  the  cellular  activity  of 
the  internal  viscera.  The  reaction  which  ensues  facilitates  gas- 
eous exchanges  and  favors  the  maintenance  of  heat  equilibrium; 
thus  producing  a  beneficial  influence  upon  the  entire  metabolic 
activity  of  the  organism. 

Climate. — Not  many  years  ago  climate  was  considered  to  be 
the  main  factor  in  the  treatment  of  tuberculosis.  It  was  thought 
that  if  a  patient  could  live  under  certain  climatic  influences,  that 
his  chances  of  cure  would  be  good;  and,  further,  that  if  he  could 
not  obtain  such  climatic  change,  little  could  be  expected. 

For  a  time  it  was  thought  that  these  favorable  climatic  condi- 
tions were  found  only  in  the  high  mountains.  This  idea  was 
based  on  an  article  published  in  the  Edinburgh  Journal  in  1848 
by  Archibald  Smith,  who  visited  the  Andes  and  noted  that,  while 
tuberculosis  was  extremely  common  at  Quito,  there  was  very 
little  in  the  mountains  above  this  city;  consequently,  he  came  to 
the  conclusion  that  there  was  an  immune  zone  somewhere  be- 
tween the  altitude  of  Quito  and  the  small  cities  of  the  moun- 
tains. This  observation  was  confirmed  in  other  high  mountain 
resorts.  It  was  seen  that  while  there  was  much  tuberculosis  in 
the  large  cities  of  Germany  and  France,  there  was  little  in  the 
high  altitudes;  while  there  was  much  tuberculosis  in  our  east- 
ern cities,  there  was  little  in  the  Rockies;  consequently,  it  was 
accepted  as  a  fact  that  treatment  at  high  altitude  offered  the 
best  chances  of  cure. 

Further  observation,  shows  that  there  is  no  zone  immune  to 
tuberculosis.  Tuberculosis  exists  in  all  sections  of  the  globe, 
and  under  all  climatic  conditions.  It  is  most  prevalent  where 
people  mass  together,  being  particularly  common  in  cities.    It  is 


648  PROGNOSIS 

an  economic  and  social  disease.  In  the  sparsely  settled  districts, 
whether  they  be  at  an  elevation,  or  at  sea  level,  or  even  below 
sea  level,  as  in  our  own  Salton  Desert,  and  the  Steppes  of  Russia, 
there  is  very  little  tuberculosis.  Tuberculosis  can,  and  will,  de- 
velop anywhere.  People  are  infected  in  childhood.  They  carry 
the  bacilli  in  their  tissues  as  they  grow  older;  and,  if  conditions 
are  brought  about,  which  tend  to  lower  their  resisting  power,  the 
bacilli  may  spread,  multiply,  and  produce  clinical  tuberculosis. 
Such  alterations  in  defensive  powers  are  less  apt  to  occur  where 
hygienic  conditions  are  maintained  and  where  people  live  lives 
conducive  to  strength,  as  they  do  in  country  districts.  We  must 
not  forget  the  influences  exerted  upon  the  body  metabolism  by 
sunlight  and  humidity  and  other  physical  principles.  There  is 
no  question  that  conditions  more  favorable  to  metabolism  are 
found  in  climates  which  favor  an  out-of-door  life,  which  have  a 
large  percentage  of  sunshine  and  low  humidity,  as  compared  with 
areas  where  dampness  and  cloud  prevail.  A  country  which  in- 
vites the  patient  to  be  out  of  doors,  and  which  offers  physical 
surroundings  in  the  way  of  natural  scenery  and  vegetation  which 
are  pleasing  to  the  physical  sense,  will  undoubtedly  improve  the 
patient's  chances  of  recovery  (see  Volume  II,  Chapter  XXXVII). 

Heliotherapy. — Heliotherapy  adds  to  the  patient's  chances  of 
cure.  In  superficial  lesions,  particularly  those  accompanied  by 
ulceration,  the  curative  influence  of  sunlight  is  quite  marvelous. 
Many  ulcerations  which,  formerly,  proved  very  difficult  to  handle, 
by  long  tried  surgical  methods,  have  yielded  quite  readily  to 
modern  sun  and  air  treatment.  While  these  may  be  aided  to  a 
certain  extent  by  exposure  to  the  air,  exposure  to  sunlight  seems 
to  have  an  added  curative  influence. 

The  effect  of  sunlight,  however,  is  not  confined  to  its  influ- 
ence on  local  lesions.  The  influence  which  it  has  upon  metabol- 
ism, through  its  stimulating  effect  upon  the  surface  of  the  body, 
is  an  important  factor.  We  must  not  lose  sight  of  the  fact  that 
a  very  important  effect  in  heliotherapy  may  be  its  influence  upon 
the  blood  which  circulates  through  the  superficial  capillaries. 
Heliotherapy  should  be  employed  as  an  important  physical  meas- 
ure in  building  up  the  patient  and  improving  his  general  resist- 
ing power.    Unfortunately,  it  can  be  used  only  to  a  limited  ex- 


CHARACTER   OF   TREATMENT  649 

tent  in  some  climates;  but,  wherever  the  sun  shines,  heliotherapy 
can  be  utilized  to  some  extent,  although  not  to  its  fullest  ad- 
vantage (see  Volume  II,  Chapter  XLIII). 

Hydrotherapy. — This  is  a  measure  which  can  be  used  in  any 
climate  and  adapted  to  all  conditions,  providing  the  physician 
understands  the  physiological  effects  of  water.  I  have  never  seen 
a  patient  to  whom  baths  could  not  be  advantageously  adjusted. 
Much  of  the  failure  in  the  application  of  hydrotherapy  has  been 
due  to  the  fact  that  the  use  of  water  seems  so  simple.  When  one 
realizes,  however,  that  the  condition  of  the  patient,  the  pres- 
ence or  absence  of  toxemia,  the  condition  of  his  superficial  blood 
vessels,  the  state  of  his  metabolic  activity,  the  condition  of  the 
atmosphere  which  surrounds  him,  the  temperature  of  the  water, 
the  mechanical  impact  of  the  same,  and  the  use  or  non-use  of  fric- 
tion during  and  after  its  application,  are  all  variables  which  enter 
into  the  effect  produced,  one  can  see  that  attention  to  detail  in 
its  application  is  absolutely  essential  to  success.  When  adapted 
to  the  needs  of  the  individual,  however,  we  have  in  hydrotherapy 
a  very  useful  measure  for  improving  the  patient's  metabolic  ac- 
tivity and  increasing  his  power  to  overcome  disease  (see  Chapter 
XLII). 

Food. — The  prognosis  in  tuberculosis  depends  upon  a  sufficient 
dietary.  No  matter  what  other  measures  are  employed,  a  suf- 
ficient amount  of  food  must  be  used  by  the  patient  if  he  is  to 
regain  health.  While  he  may  go  through  periods  when  the 
amount  of  food  eaten  is  not  sufficient  to  supply  the  demands  of 
his  body,  yet,  if  these  are  long  continued,  malnutrition  will  fol- 
low, which  greatly  interferes  with  the  patient's  chances  of  cure. 

There  has  been  much  discussion  about  what  constitutes  an 
adequate  dietary.  There  is  no  unanimity  of  opinion  as  to  what 
dietary  is  the  most  useful  for  the  tuberculous  patient;  at  the 
same  time,  all  agree  that  the  patient  should  be  supplied  with  a 
sufficient  number  of  calories  to  take  care  of  his  ordinary  meta- 
bolic changes,  plus  the  extra  demands  which  are  made  upon  him 
by  his  disease,  and  still  have  a  surplus  for  increasing  his  defen- 
sive powers.  Some  observers  favor  a  diet  rich  in  fats;  others 
rich  in  protein;  and,  occasionally,  we  find  someone  who  believes 
that  extra  large  amounts  of  carbohydrates  should  be  employed. 


650  PROGNOSIS 

Suffice  it  to  say,  that  our  digestive  capabilities  are  such  that  when 
reinforced  by  the  metabolic  activities  of  the  cells,  we  are  able  to 
derive  sufficient  nutriment  from  dietaries  which  are  not  formed 
according  to  our  scientific  ideas.  A  patient  can  nourish  him- 
self on  foods  which  are  largely  carbohydrate,  largely  protein,  or 
largely  fat;  at  the  same  time,  it  is  undoubtedly  wise  to  supply 
the  body  with  foods  belonging  to  each  of  these  classes  in  quan- 
tities which  experiments  have  shown  to  be  the  most  rational. 

From  the  prognostic  standpoint,  nutrition  is  the  goal  to  be 
aimed  at,  not  fat.  Nothing  is  gained,  however,  by  putting  on 
weight  if  it  is  necessary,  in  order  to  do  so,  to  give  the  patient 
large  quantities  of  food  over  a  prolonged  period  of  time.  Over- 
feeding is  still  too  commonly  found  in  the  treatment  of  this  dis- 
ease. The  patient  is  led  to  believe  that  if  only  he  can  keep  fat 
he  will  get  well.  Fat  is,  prognostically,  bad  rather  than  good. 
The  fat  patient  is  soft,  not  resistant.  He  has  too  much  extra 
tissue  to  care  for,  without  having  a  corresponding  increase  in 
strength  and  vigor  (see  Volume  II,  Chapter  XXXIX). 

Rest  and  Exercise. — The  prognostic  influence  of  rest  is  recog- 
nized by  all  students  of  phthisiotherapy.  In  the  writer's  personal 
experience,  he  has  gradually  learned  to  have  great  respect  for 
the  influence  of  these  two  measures  when  properly  applied.  I 
am  sure,  as  I  look  back  on  some  of  the  results  in  my  early  prac- 
tice, that  many  failures  could  have  been  prevented  had  I  fully 
realized  the  importance  of  rest  in  treatment.  A  patient's  chances 
of  recovery  are  increased  greatly  if  he  is  confined  to  bed  during 
the  entire  period  of  not  only  clinical  activity,  as  expressed  in 
the  symptoms  which  accompany  toxemia,  but  also  during  the 
period  when  there  are  widespread  lesions  in  the  lung,  accom- 
panied by  signs  and  symptoms,  which  indicate  that  the  patho- 
logical changes  are  still  taking  place  rapidly.  I  am  inclined  now 
to  keep  my  patients  at  rest  until  I  feel  reasonably  certain  that 
there  is  no  further  danger  of  necrosis  and  caseation  taking  place. 
While  it  is  difficult  to  assign  to  the  various  measures  which  we 
employ  their  true  part  in  the  production  of  a  favorable  result, 
yet  I  am  sure  that  I  cannot  emphasize  too  strongly  the  prog- 
nostic importance  of  rest  during  the  early  months  of  treatment 
of  all  patients  who  are  suffering  from  tuberculosis, 


CHARACTER   OF  TREATMENT  651 

Exercise  is  likewise  a  valuable  adjunct  and  adds  greatly  to 
the  chances  of  cure  by  improving  the  patient's  metabolism  and 
making  him  strong  and  more  resistant.  It  does  this,  however, 
only  when  it  is  nicely  adjusted  to  the  individual  patient's  par- 
ticular pathology.  If  one  is  to  err  in  prescribing  either  rest  or  ex- 
ercise, let  it  be  on  the  side  of  rest  (Volume  II,  Chapter  XXXVIII) . 

Psychotherapy. — As  mentioned  elsewhere  in  this  monograph, 
one  of  the  factors  which  is  capable  of  doing  most  good  in  the 
treatment  of  tuberculosis  is  psychotherapy.  If  employed  to  its 
fullest  value,  it  can  even  make  up  some  of  the  deficiencies  which 
come  from  a  failure  to  fully  utilize  other  measures.  I  have  often 
said  that  I  would  rather  have  a  patient  treated  in  a  room,  if 
I  could  give  him  the  benefit  of  hydrotherapy  and  psychother- 
apy, with  good  food,  than  treat  him  in  the  open  air,  with  hy- 
drotherapy and  psychotherapy  omitted.  The  contentment  and 
cooperation  of  the  patient  is  such  an  important  factor  that  I  can- 
not emphasize  too  strongly  the  importance  of  this  measure  in  the 
treatment  of  tuberculosis.  The  effect  of  this  measure  is  illus- 
trated by  an  incident  which  came  under  the  writer's  notice  re- 
cently. Two  physicians  were  treating  the  same  group  of  pa- 
tients,— one  of  whom  had  a  strong  personality  and  used  psycho- 
therapy to  its  full  value,  while  the  other  lacked  magnetism  and 
was  more  or  less  mechanical  in  his  methods.  A  patient  was  going 
to  the  office  for  treatment  and  was  sometimes  treated  by  one  and 
sometimes  by  the  other.  One  day  the  patient  remarked  to  the 
physician  first  described:  "I  do  not  know  why  it  is;  you  and 
your  associate  use  the  same  measures,  and  both  give  tuberculin 
in  the  same  manner,  but  when  I  leave  your  associate  I  feel  that 
I  have  had  nothing  but  the  injection.  When  I  leave  you  I  feel 
happy,  contented,  and  relieved  of  all  apprehension  for  the  day." 
This  experience  is  not  an  uncommon  one.  Personality  is  a  great 
factor  in  medicine.  All  physicians  who  are  desiring  to  be  suc- 
cessful in  the  treatment  of  a  chronic  disease  like  tuberculosis 
should  cultivate  cheerfulness,  optimism,  friendliness  and  sym- 
pathy, that  they  may  give  their  patients  not  only  the  benefit  of 
the  usual  physical  measures,  but  also  the  full  physiological  benefit 
that  comes  from  a  helpful  psychic  attitude  (see  Volume  II,  Chap- 
ter XLI). 


652  PROGNOSIS 

Tuberculin. — Of  all  the  remedies  used  in  tuberculosis,  tuber- 
culin is  the  only  one  that  has  a  direct  specific  influence  upon  the 
tuberculous  tissue.  Tuberculin  is  employed  in  the  treatment  of 
tuberculosis  for  two  distinct  purposes;  one,  that  of  producing 
immunity  against  the  products  of  the  tubercle  bacillus;  the 
other,  that  of  producing  a  focal  reaction  which  stimulates  the  pro- 
duction of  fibrosis. 

It  was  formerly  thought  that  the  production  of  immunity  was 
the  chief  function  of  tuberculin ;  but,  as  we  study  its  action  more 
and  more,  this  seems  to  be  open  to  question.  There  is  no  doubt 
that  any  foreign  protein  will  produce  an  immunity  against 
itself,  so  that  the  various  components  of  the  tubercle  bacillus, 
which  are  found  in  the  individual  preparation  of  tuberculin  em- 
ployed must,  of  necessity,  establish  a  resistance  on  the  part  of 
the  body  cells  against  themselves;  and  there  is  further  no  doubt 
that  this  has  considerable  influence  in  keeping  up  a  specific  re- 
sistance against  the  tubercle  bacillus;  but  in  most  cases  of  tu- 
berculosis, resistance  to  the  bacillus  is  already  high,  and  an 
increased  immunity  is  not  so  important.  The  patient  constantly 
gives  himself  doses  of  bacillary  products  from  his  own  focus; 
and,  in  this  way,  gets  the  identical  stimulation  which  is  essential 
to  the  production  of  a  full  immunity  against  the  bacillus.  As 
far  as  we  know,  we  are  not  able  to  obtain  this  regularly  by  any 
preparation  of  tuberculin  that  we  have  hitherto  employed. 

Any  specific  product  made  from  the  tubercle  bacillus,  how- 
ever, possesses  the  peculiar  properties  of  producing  a  reaction 
between  itself  or  the  products  which  result  from  its  chemical 
decomposition,  and  the  body  cells.  When  this  reaction  occurs 
in,  and  near  the  focus  of  infection,  it  produces  a  stimulation, 
which  results  in  hyperemia  or  congestion,  which  hastens  healing. 

When  tuberculin  is  intelligently  employed  it  favorably  in- 
fluences prognosis.  It  is  as  difficult  to  estimate  fully  the  value 
of  tuberculin  in  the  treatment  of  tuberculosis  as  it  is  to  estimate 
the  value  of  fresh  air,  good  food,  psychotherapy,  and  climatic 
conditions;  because  when  tuberculin  is  used,  many  of  the  other 
measures  are  likewise  employed.  After  twenty  years'  experience 
in  the  use  of  tuberculin,  I  have  no  hesitancy  in  saying  that  this 
remedy,  when  properly  suited  to  the  individual  patient  under 


CHARACTER   OF   TREATMENT  653 

treatment,  and  not  given  haphazardly,  or  by  routine,  will  add  at 
least  a  minimum  of  20  per  cent  to  the  chances  of  healing. 

I  further  believe  that,  if  carried  out  sufficiently  long  the  tuber- 
culin treatment  will  unquestionably  produce  a  firmer  scar  and 
more  complete  healing.  It  is  my  observation  that  those  patients 
who  have  been  successfully  treated  with  tuberculin  and  in  whom 
the  treatment  has  been  kept  up  for  a  sufficient  length  of  time, 
show  less  tendency  to  relapse  than  those  who  are  treated  by 
the  usual  dietetic,  hygienic  measures  alone. 

Tuberculin  is  not  a  remedy  that  can  be  used  to  best  advantage 
by  men  who  are  unaccustomed  to  its  use ;  consequently,  its  favor- 
able influence  will  have  to  be  denied  to  a  large  percentage  of 
those  who  are  suffering  from  this  disease.  The  value  of 
this  remedy  has  been  recognized  for  a  long  time  by  those 
who  are  ordinarily  opposed  to  its  general  use,  in  those 
cases  which  have  failed  to  make  satisfactory  progress  with- 
out its  employment.  They  justify  its  use  in  such  cases  by  saying 
that  it  seems  to  furnish  the  stimulation  necessary  to  start  these 
cases,  which  have  hitherto  failed  to  respond  to  ordinary  measures, 
on  the  road  to  recovery.  If  of  value  in  these  cases,  it  stands  to 
reason  that  it  must  be  of  value  in  others,  although  its  influence 
might  not  be  so  apparent  in  those  which  show  a  general  tendency  to- 
ward healing  without  it.  When  one  bears  in  mind,  however, 
that  any  healing  that  occurs  in  tuberculosis  takes  place  because 
of  the  specific  focal  stimulation  produced  by  the  products  of  the 
tubercle  bacillus,  the  rationale  of  this  remedy  is  evident  (see 
Volume  II,  Chapter  XL). 

Induced  Pneumothorax. — During  the  past  decade  induced 
pneumothorax  has  been  gradually  gaining  supporters  among 
those  who  are  interested  in  the  cure  of  tuberculosis.  The  theory 
on  which  its  employment  rests  is  that  it  puts  the  diseased  organ 
at  rest;  compresses  the  areas  of  activity  and  necrosis;  prevents 
the  absorption  of  toxins ;  and,  by  so  doing,  relieves  the  patient  of 
the  debilitating  action  of  toxins  and  enables  him  the  better  to 
build  up  his  defensive  powers.  Induced  pneumothorax  is  sup- 
posed to  be  applicable  only  to  one-sided  lesions,  although  it  has 
been  tried  by  some  during  more  recent  times,  where  both  lungs 
were  involved,  compressing  one  side  at  a  time. 


654  PROGNOSIS 

That  pulmonary  compression  at  times  aids  in  the  enre  of  tu- 
berculosis cannot  be  denied,  and  there  is  no  doubt  in  my  mind 
but  that  many  men  will  give  their  patients  better  chances  of 
cure  by  putting  the  lung  at  rest,  and  filling  the  pleural  sac 
with  gas  than  they  would  by  not  doing  so.  On  the  other  hand, 
the  percentage  of  cases  where  it  is  essential  to  cure,  from  my 
observation,  are  very  few.  The  cure  of  tuberculosis,  even  when 
induced  pneumothorax  is  used,  does  not  consist  alone  in  filling 
the  pleural  sac  with  gas.  This  must  be  kept  filled,  and  the 
patient  must  be  cared  for  and  treated  the  same  as  when  this  is 
not  used.  Its  final  effects  must  also  be  considered.  There  are  a 
certain  number  of  accidents  which  attend  its  employment,  such 
as  pleural  shock,  rupture  of  a  cavity  wall,  pyopneumothorax,  and 
causing  the  disease  to  become  more  active  in  the  other  lung. 
The  after-effects  must  also  be  considered.  From  the  physiological 
standpoint  it  is  impossible  to  compress  the  entire  lung  over  a  pro- 
longed period  of  time,  without  producing  a  severe  strain  upon 
the  heart.  There  is  considerable  question  whether  at  the  end 
of  the  period  of  a  few  months  or  a  year  or  more,  that  is 
necessary  to  produce  a  result  by  this  measure,  the  heart  will 
not  have  been  subjected  to  a  strain  which  will  eventually  prove 
to  be  the  patient's  undoing.  The  ordinary  hygienic  treatment, 
with  proper  psychotherapeutic  influences  and  tuberculin  added, 
under  ideal  conditions,  is  probably  more  satisfactory  and  more 
rational  in  the  handling  of  the  disease  than  is  induced  pneumo- 
thorax ;  nevertheless,  there  are  many  patients  who  for  one  reason 
or  another,  cannot  be  given  these  other  measures  to  best  ad- 
vantage for  whom  induced  pneumothorax,  with  other  helpful 
measures  that  can  be  employed,  will  offer  better  chances  of  cure 
than  though  it  were  omitted.  In  estimating  the  value  of  this 
measure  one  must  bear  in  mind  that  it  is  good  lung  tissue  which 
collapses  first;  consequently,  if  full  value  is  to  be  obtained  from 
its  employment,  the  compression  must  be  complete  (see  Volume 
II,  Chapter  XLIV.) 

Pharmacological  Remedies. — Pharmacological  remedies,  now 
and  then,  have  a  very  important  influence  in  the  treatment  of 
tuberculosis.  There  are  certain  remedies  which  are  of  great 
value  in  improving  the  symptoms  and  complications  which  exist, 


CHARACTER   OF   TREATMENT  655 

and  without  which  it  would  be  very  difficult  to  treat  the  patient 
successfully.  Among  such  may  be  mentioned  the  various  forms 
of  opium  used  for  pain  and  cough;  atropin  to  combat  many  of 
the  vagotonic  conditions;  hydrochloric  acid,  in  cases  of  deficient 
gastric  secretion;  laxatives  which,  of  course,  should  be  reduced 
to  the  minimum,  the  condition  of  the  bowels  being  controlled 
as  largely  as  possible  by  dietary  and  other  measures;  sedatives, 
other  than  opiates,  such  as  the  bromides,  for  the  relief  of  nervous- 
ness; remedies  for  sleep,  when  this  cannot  be  induced  by  other 
measures;  and  last,  but  not  least,  we  must  not  forget  such 
preparations  as  digitalis,  strychnine,  iron  and  arsenic,  which  can 
often  be  used  to  the  advantage  of  the  patient. 

In  speaking  of  the  prognostic  value  of  pharmacological 
remedies  we  must  bear  in  mind  that  the  relief  of  troublesome 
symptoms  is  often  of  inestimable  value  to  the  patient.  Some 
symptoms,  such  as  pain  and  sleeplessness,  while,  in  themselves, 
not  so  dangerous,  produce  certain  impressions  upon  the  nerve 
cells  which  result  in  depression  and  general  interference  with 
cellular  activity;  so,  we  cannot  ignore  the  importance  of  these 
common  symptoms  in  their  effect  upon  the  prognosis  in  tuber- 
culosis. We  can  favorably  influence  prognosis  by  relieving 
nagging,  distressing  symptoms  and  complications;  so,  we  must 
not  neglect  the  little  things  that  add  comfort  and  make  for  con- 
tentment and  happiness  during  the  long  period  necessary  for 
cure  (see  Volume  II,  Chapter  XL VI). 

Change  of  Occupation. — Much  foolish  advice  is  often  given  to 
patients  suffering  from  tuberculosis,  or  who  have  recently  ob- 
tained an  arrestment  of  their  disease.  Probably  no  advice  is 
given  more  readily  than  that  of  telling  the  patient  to  change  his 
occupation, — to  get  out  in  the  open  air.  Such  advice  should  not 
be  given  so  readily;  and  during  recent  years,  instead  of  advising 
my  patients  to  change  their  occupation,  and  get  out  in  the  coun- 
try, I  have  been  looking  upon  the  matter  from  what  I  believe  is  a 
more  sensible  standpoint.  The  occupation  followed  by  the  pa- 
tient, as  a  rule,  occupies  about  one-third  of  his  time.  It  is  not 
so  much  what  the  patient  does  during  the  one-third  of  the  time 
as  it  is  the  other  two-thirds  of  his  time  that  determines  whether 
or  not  he  is  to  regain  his  health. 


656  PROGNOSIS 

Oftentimes  patients  are  told  to  go  to  the  country  and  take  up 
some  new  work,  for  which  they  are  totally  unfitted  by  nature, 
and  are  often  unable  to  do  financially.  The  result  is  that  the  pa- 
tient obtains  the  fresh  air  but  is  compelled  to  learn  a  new  oc- 
cupation and  to  make  financial  sacrifices  which  greatly  reduce  his 
comfort,  and  interfere  with  his  state  of  health.  It  is  more  sen- 
sible when  a  patient  consults  a  physician  as  to  his  occupation, 
to  find  out  whether  or  not  he  does  his  work  easily,  whether  he 
knows  the  work  that  he  has  been  doing;  and  if  he  does  it  easily, 
tell  him  to  continue  it,  but  to  look  well  to  the  other  two-thirds  of 
the  twenty-four  hours  which  remain  after  his  work  is  done.  If 
he  will  give  himself  proper  rest,  see  that  he  has  substantial 
food,  sleep  out  of  doors,  and  avoid  excess,  the  eight  hours  of 
work  in  the  office,  or  mill,  or  shop,  as  a  rule,  will  be  no  more 
harmful  to  him  than  undertaking  to  master  a  new  work,  or  new 
profession  for  which  he  has  no  particular  aptitude  and  which 
causes  an  entire  rearrangement  of  his  life  and  habits,  even  though 
the  latter  is  in  the  open.  This  fact  is  better  understood  now  that 
we  know  that  it  is  not  the  lack  of  oxygen  in  the  inside  air  that 
proves  harmful  (see  Volume  II,  Chapter  XXXVI). 


INDEX 


Abscess,  pulmonary,  case  illustrating, 
ii.     585 
symptoms  of,  ii.     585 
Aching,  general,  part  of  syndrome  of 

toxemia,  ii.     110 
Acidosis  in  tuberculosis,  i.     456 
produced  by  deficiency  in  oxygen, 
ii.     281 
Acromion  process  in  advanced  tuber- 
culosis, i.  471 
Actinomycosis,  differentiated  from  tu- 
berculosis, i.     620 
Activity,  clinical,  no  evidence  of,  in 
percussion,  i.     426 
meaning  of,  ii.  549 
waves  of,  common  in  advanced  tu- 
berculosis, ii.     575 
Adolescence  and  tuberculosis,  i.     109 

period  of  low  resistance,  ii.     199 
Adrenal  gland,  developmentally  a  part 
of  sympathetic  system,  i.  173 
part  of  chromaffin  system,  i.  173 
Adrenals,  stimulated  when  sympathet- 
ica stimulated,  i.     219 
Adrenin,  action  of,  i.     219 

in  prolonging  toxic  symptoms,  i. 
605 
acts  at  myoneural  junction,  i.     173 
in  treatment  of  asthma,  ii.  167 
Adults,  danger  of  being  infected  from 
without,  i.     89 
early  clinical  tuberculosis  in,  ii.  506 
open  tuberculosis  in,  ii.     509 
Aeby,  description  of  growth  of  lung, 

i.     127 
Aerogenous  infection,   i.  65 

difficulties  of,  i.     67 
Age  periods,  statistics  of,  healing,  i. 
97 
mortality,  i.  97,  98 
tuberculosis   differs  in  different,  i. 
96 
Air,  beneficial  effects  of,  due  to  phys- 
ical properties  and  mechan- 
ical action,  ii.  231 
city  vs.  country,  ii.  264 


Air— Cont  'd 

cold,  effect  of,  depends  on  reactive 
powers  of  patient,  ii.  272 
vs.  warm,  ii.  271 
confined,  favors  infection,  ii.  246 
deleterious  effect  of  carbon  dioxide, 

not  proved,  ii.  230 
diathermacy   of,  increased  at    alti- 
tude, ii.  270 
effects  of,  produced  on  nerve  end- 
ings of  skin,  ii.  271 
expired,  organic  poison  in,  ii.  234 
inside  and  outside,  differ,  ii.  245 
lack  of   motion   in,   produces   heat 

stagnation,  ii.  235 
movement    of,    diminished    in    city 
compared    with    country,    ii. 
264 
movement  of,  influence  on  body,  ii. 

236,  243,  258 
open  (see  Open  air) 
stale,  deleterious  effects  of,  ii.  231 
supposed  diminution  of  oxygen  in, 

ii.  232 
supposed  effect  of  excess  of  carbon 
dioxide  in,  ii.  233 
Air  baths  in  fever,  ii.  455 
Air-borne  disease  differs  from  blood- 
borne,  i.  33,  67 
Air  cells  in  different  parts  of  lung  ex- 
pand unequally,  i.  145 
Albers-Schonberg,     cause     of     trunk 
shadows  in  lung  plate,  i.  522 
Albrecht,    E.,    and    H.,    and   primary 

lung  focus,  i.  66 
Albumin    reaction    in    sputum,    diag- 
nostic value  of,  i.  538,  582 
Alcohol  bath  should  not  be  used,  ii. 

412 
Alimentary  infection,  i.  69 
Altitude,  changes  in  blood  at,  ii.  259 
formerly  thought  to  be   necessary, 
i.   647 
Alvarez,  studies  on  motility  of  intes- 
tinal canal,  ii.  40 
Amyloid  degeneration,  i.  43 

in  gastrointestinal  tract,  i.  280 
Anaphylaxis,  ii.  157,  158 


658 


INDEX 


Anaphylaxis,  and  asthma,  ii.  157,  161 
and  hay  fever,  ii.  157,  161 
and  shell  fish  poisoning,  ii.  157,  161 
and  toxemia  contrasted,  ii.  158,  341 
and  tuberculin  reaction,  ii.  162 
and  vegetative  nervous    system,   ii. 

157 
bladder  in,  ii.  160 
blotching  of  skin  in,  ii.  160 
bronchial  secretion  in,  ii.  159 
bronchial  spasm  in,  ii.  159 
collapse  in,  ii.  160 
diarrhea  in,  ii.  159 
due  to  peripheral  vagus  stimulation, 

ii.  343 
fall  in  temperature  in,  ii.  160 
fatal,  central  nervous  system  in,  ii. 

160 
itching  of  skin  in,  ii.  160 
low  blood  pressure  in,  ii.  160 
motility   of   intestinal   tract   in,   ii. 

160 
nausea  in,  ii.  159 
perspiration  in,  ii.  160 
prevented  by  atropin,  ii.  343 
sphincters   in,   ii.    160 
syndrome  of,  ii.  159 

due  to  central  plus  vague  stimu- 
lation, ii.  343 
urticaria  in,  ii.  157 
vomiting  in,  ii.  159 
Anatomical  facts,  important  in  chest 

examinations,  i.  319 
Anemia,   and   early    clinical   tubercu- 
losis, i.  364 
arterial,  cause  of,  i.  303 
following  severe  hemorrhage,  ii.  172 
Anergie,  cause  of  metastases,  i.  36 
Aneurism,  cause  of  large  per  cent  of 

fatal  hemorrhages,  ii.  172 
Anger,   effect   on  temperature   curve, 

ii.  148 
Animals,  experiments  on,  with  tuber- 
culin inconclusive,   ii.    333 
explanation  of  immunization  of,  ii. 

334 
relation  to  tuberculin  not  the  same 
as  that  of  human  beings,  ii. 
334 
not  easily  immunized  with  tubercu- 
lin, ii.  333 
Antibody,  formation  of,  favored  by 

fever,  ii.  118 
Antiformin     method     of     examining 
sputum,  i.  556 


Antigen-antibody  reaction,  tuberculin 

an,   i.   503,    513 
Apathy  toward  tuberculosis,  cause  of, 

ii.  187 
Apex,  compression  of,  follows  anatom- 
ical growth,  i.  134 
first  pulmonary  metastases  form  in, 

i.  36,  87 
hardness    of    tissues    over,    denotes 

disease,  i.  415 
lessened  respiratory  motion,  predis- 
poses to  infection,  i.  38,  134 
why  involved  in  adult  and  not  in 
child,  i.  117  to  147 
Apical   infection  and   shortened  first 

rib,  not  parallel,  i.  145 
Apices,  frequency  of  infection  of,  in 
adults,  i.   Ill,  406,  408,  ii. 
191 
Appendix,  tuberculosis  of,  ii.  40,  653 

operation  for,  ii.  593 
Appetite,   improved   by  open   air,   ii. 
248 
psychotherapy,  ii.  394     • 
in  tuberculosis,  i.  255 
lack  of,  part  of  syndrome  of  tox- 
emia, ii.  110 
loss  of,  caused  by  toxemia,  i.  370; 
ii.  314 
Arneth's  classification  of  neutrophiles, 

i.  577 
Arnsperger,  cause  of  trunk  shadows  in 

lung  plates,  i.  522 
Arsenic  in  treatment  of  tuberculosis, 

ii.  465 
Arteries,  small  in  tuberculosis,  i.  46 
Arteries,  thickening  of,  in  tuberculo- 
sis, i.  44,  240 
withstand  necrotic  process  in  tuber- 
culosis   and    resist    oblitera- 
tion, ii.  171 
Aspergillosis   differentiated  from   tu- 
berculosis, i.  621 
Asthenia,  general,  and  tuberculosis,  i. 
612 
case  illustrating,  ii.  607 
Asthenic  type  of  individual,  charac- 
teristics of,  i.  340 
Assmann,  accuracy  and  limitations  of 
x-ray,  i.  521 
shows  trunk  shadows  due  to  blood 
vessels,  i.  522 
Asthma,  ii.  164 
adrenin  in,  ii.  167 
and  anaphylaxis,  ii.  157,  161 
atropin  in,  ii.   167 


INDEX 


659 


Asthma — Cont  'd 

bronchitis  a  cause  of,  ii.  164 
complicating   pulmonary   tuberculo- 
sis, case  illustrating,  ii.  605 
definition  of,  ii.   166 
due  to  peripheral  protein  irritation, 

ii.  166 
dust,  vapor,   and  atmospheric   con- 
dition, in  cause  of,  ii.  164 
etiology  of,  ii.  164 
occurs  in  those  who  have  other  vago- 
tonic symptoms,  ii.  166,  177 
produced  reflexly  by  stimulation  of 
many    branches    of    greater 
vagus,  ii.  165 
reflex  cause  of,  ii.  164 
relieved  by  sympathetic  stimulation 
caused  by  toxemia,   ii.   161, 
167 
symptoms  of,  ii.  164 

due  to  increased  vagus  tonus,  ii. 
167 
treatment   of,   case   illustrating,   ii. 
167,  605 
Atmosphere,   humidity    and   tempera- 
ture   of,     influence    of,     on 
body,  ii.  258 
Atrophy,  regional,  as   sign  of  intra- 

pulmonary  disease,  i.  412 
Atropin  in  night  sweats,  ii.  451 
spastic  constipation,  i.  277 
treatment    of    vagotonic    condition, 
ii.  169 
Atropin,  in  treatment  of  asthma,  ii. 
167 
hyperchlorhydria,  i.  261 
tuberculous    enteritis,    case   illus- 
trating, ii.  648 
prevents  anaphylaxis,  ii.  343 
Auer  and  Lewis,  studies  in  anaphy- 
laxis, ii.  343 
Auscultation    and   abdominal   breath- 
ing, i.  428 
Auscultation,  difficult  in  early  tuber- 
culosis, i.  610 
early  diagnosis  should  not  depend 

on,  i.  427 
effects  produced  on,  by  changes  in 
soft   tissues,  ii.   61 ;    i.   428, 
431 
extrapulmonary  rales  on,  i.  482 
i    factors  causing  changes  in,  i.  397 
harsh  breathing  on,  i.  479 
in  advanced  tuberculosis,  i.  478 
in  early  pulmonary  tuberculosis,  i. 
426;  ii.  526 


Auscultation — Cont  'd 

in  emphysema,  compensatory,  i.  495 
in  extensive  fibrosis  with   necrosis, 
cases     illustrating,    ii.     544, 
556,  569,  581,  601,  611,  623, 
634,   652 
in  pleura,  thickened,  i.  497 
in  pleural  effusion,  i.  496 
in  pleurisy,  dry,  i.  496 
in  pneumothorax,  ii.  81 
in  pulmonary  cavity,  i.  491 
fibrosis,  i.  489 
infiltration,  i.  488 
influence    of    soft    tissues    on,    in- 
ferred from  their  thickness, 
i.  332 
intensity  of   sounds   heard  on,   de- 
creased by  pressure  on  steth- 
oscope, i.  427 
interpretation  of  findings  on,  i.  433 
method  of  breathing  during,  i.  428 
no  sounds  heard  on,  always  denot- 

-     ing  activity,  i.  407 
prolonged   expiration   on,   i.   478 
rales  on,  i.  480 
rough  breathing  on,  i.  497 
should  not  be  made  through  cloth- 
ing, i.  427 
Austrian  and  tuberculin  reaction,  ii. 

336 
Autoinoculation  and  exercise,  ii.  203 
Automobiling  not  suitable  exercise,  ii. 
300 

!       B 
Bacillary  index  for   estimating   rela- 
tive number  of  bacilli  of  dif- 
ferent lengths,  i.  565 
Bacillen  Emulsion    (B.  E.)   Koch,  ii. 

356 
Bacilli,  action  of,  in  producing  fever, 
ii.    122 

bunches  and  free,  comparative  study 
of,  i.  545 

bunches  of,  broken  up  by  chloro- 
form and  xylol,  i.  549 

carried  by  the  fly,  i.  78 

classification  according  to  method 
of  taking  stain,  i.  542 

comparative  chances  of  finding  in  1, 
2,  5,  10,  and  15  minutes 
search,  i.  542 

concentration  vs.  scattering  for  ex- 
amination, i.  552,  555 

conditions  favorable  to  implanta- 
tion of,  ii.  197 


660 


INDEX 


Bacilli— Cont'd 

course  in  blood,  i.  32 

daily  variation  of,  in  sputum  of  low 

bacillary  count,  i.  549 
danger    of   from    dried   sputum,   i. 

563 
death  of,  favored  by  sunshine  and 

dryness,  ii.  270 
difference  in  behavior  of  in  primary 

and  metastatic  infections,  i. 

84 
distribution  of,  study  of,  i.  545 
distribution      of,      by     mechanical 

shaker,  i.  554 
in  sputum,  i.  540 
dosage  of  inoculation  of,  ii.  504 
enter      uninjured      mucous      mem- 
branes, i.  30 
escape   from  foci   of   infection,   ii. 

331 
factors  interfering  with  penetration 

of  stain  in,  i.  541 
gain   access    to    blood    stream    and 

produce  fever,  ii.  156 
good  technic  for  examination  for, 

essential,  i.  541 
grown   on   one   tissue   favor   same 

tissue      in      new      infection 

(Rosenow),  i.  32 
growth   of,    checked   by   fever,   ii. 

118 
implantation  of,  favored  by,  i.  37 
indirect  methods  of  demonstrating, 

i.  560 
in  feces,  ii.  513 
infection  by,  and  cell  sensitization, 

i.  34 
inoculation    of,   begins    soon    after 

birth,  ii.   195 
in  stool  of  tuberculous,  i.  52 
in  stool  in  tuberculous  enteritis,  ii. 

41 
in   tissues    without   producing   his- 
tological tubercle,  i.  65 
intertransmissibility  of  bovine  and 

human,  i.   57 
life  of,  favored  by  cloud  and  mois- 
ture, ii.  270 
long,  in  more  chronic  lesions,  i.  592 
method  of  estimating  number  in  24 

hr.  specimen,  i.  562 
finding,  when  rare,  i.  549 
morphological    classification    of,    i. 

564 
multiply   when   activity  present,   i. 

368 


Bacilli— Cont  'd 

multiplication  of  means  activity,  ii. 
190 

mutation  of  type  of,  i.  65 

number  in  sputum,  i.  561 

once  in  vessel  may  infect  any  or- 
gan of  body,  i.  124 

pass  through  glands  in  childhood, 
i.   31 

penetrate  blood  vessel  walls,  i.  124 
intestinal    wall    easily    in    child- 
hood, i.  71,  100 

pig  inoculation  to  determine,  1.  560 

presence  and  form  of,  in  prognosis, 
i.  633 

secretion  from  mucous  membrane 
may  be  contaminated  by,  i. 
563 

short,  from  actively  breathing  down 
areas,  i.  592 

solvents  for  wax  of,  i.  548 

sputum  culture  of  Petroff,  i.  560 

staining  for,  i.  556 

tubercle  differentiated  from  smeg- 
ma,   i.    559 

virulence  of,  in  fibroid  tuberculosis, 
i.  40 

wet  method  of  preparing  slides  for 
examination  for,  i.  556 
Bacteria,  defense  against,  i.  218 

effect  of  light  on,  ii.  418 

multiplication  of,  prevented  by  fe- 
ver, i.  373 
Baldwin  and  artificial  immunization, 

ii.  335 
Baldwin    and    tuberculin    hypersensi- 
tiveness,  i.  506 
reaction,  ii.  336 

tuberculin  reaction  and  anaphylaxis, 
ii.  341 
Barlow,  discussion  of  climate,  ii.  255 
Bartel,  incubation  period  in  tubercu- 
losis, i.   65 
Bateman  discusses  food  value  of  raw 

eggs,  ii.  325 
Bath,  alcohol,  should  not  be  used,  ii. 
412 

cleansing,  ii.  412 

cold  sponge,  ii.  407 

conditions  governing,  ii.  404 

during  hemorrhage,  ii.  183 

effect  of,  depends  on  warmth  and 
degree  of  impact,  ii.  402 
on  temperature,  ii.  154 

foot,  importance  of,  ii.  412 

hot  and  cold,  effects  of,  ii.  405 


INDEX 


661 


Bath— Cont'd 

influences  all  parts  of  body,  ii.  402, 

404 
neutral,  effects  of,  ii.  405 
reaction  after,  ii.  406 
spray,  ii.  409 
sun,  ii.  423 
tepid  sponge,  ii.  410 
vinegar,  and  night   sweats,  ii.  451 
Bayliss,    vegetative     nervous    system 
and  endocrine  glands,  i.  169 
Bechterew,    on   mediation    in   sympa- 
thetic ganglia,  i.  191 
on  the   function  of  nerve   centers, 
i.   169 
Bennett    establishes    children's     sea- 
shore home,  ii.  268 
Biedl,  internal  secretions,  i.  169 
Biedl  and  Kraus,  studies  in  anaphy- 
laxis,   ii.    343 
Biliousness  (so-called),  i.  277 
Bladder,  in  anaphylaxis,  ii.  160 

tuberculosis    of,  ii.    101 
Blastomycosis  differentiated  from  tu- 
berculosis,   i.    621 
Blood,  and  lymph  flow  influenced  by 
stimulation  of  skin,  ii.  402 
antibacillary  elements  of,  cause  in- 
fections to  be  mild,  i.  78 
Arneth's    classification    of    neutro- 

philes  in,  i.  577 
bacilli  course  in,  i.  32 
changes  in,  at  altitude  not  evidence 
of  curative  influence,  ii.  259, 
261 
at  different  altitudes,  evidence  of 
physiological   adaptation,   ii. 
259 
part  of  syndrome  of  toxemia,  ii. 
110 
coagulability  of,  in  hemorrhages,  ii. 

178 
concentration  of,  at  altitude,  ii.  259 
condition  of  and  prognosis,  i.  639 
diagnostic  and  prognostic  value  of 

findings  in,  i.  585 
effect  of  light  on,  ii.  420 
examination  of,  i.  575 
from   cavity,    characteristics    of,   i. 

29 
general  differential  count  in,  i.  576 
occult,  in  feces,  method  of  examin- 
ing for,  i.  580 
technic  for  procuring  specimens,  i. 

576 
time  of  day  for  examining,  i.  576 


Blood-borne  diseases  differ  from  air- 
borne, i.  33 
Blood  pressure,  in  tuberculosis,  i.  235 
low,  effect  of,  i.  237,  238 

in  anaphylaxis,  ii.  160 
mechanisms  involved,  in  maintain- 
ing, i.  236 
rise  in,  in  tuberculosis,  i.  239 
Blood  spitting,  and  early  clinical  tu- 
berculosis, i.  364 
early  sign  of  tuberculosis,  i.  216 
makes  diagnosis  of  tuberculosis  al- 
most certain,  ii.  170 
symptom    of    early   tuberculosis,    i. 
390 
Blood  vessel,   aneurism   of,    cause   of 

hemorrhage,  i.  29 
Blood  vessels,    influence    of    nervous 
system  on,  i.   232 
innervation  of,  i.   175 
pathological   changes  in,  i.  44 
shadow  cast  by  in  lung  plate,  i.  522 
tuberculous  lesions  of,  i.  241 
Blood  vessel  walls,  penetrated  by  ba- 
cilli, i.  124 
Blotching  of  skin  in  anaphylaxis,  ii. 

160 
Bodington,  institutes  open  air  cure  for 

tuberculosis,  ii.  228 
Body,  segmentation  of,  importance  of 

understanding,  i.  177 
Body  heat,  eliminated  largely  through 

skin,  ii.  Ill 
Body  temperature,  normal  regulation 

of,  ii.  110 
Bone  and  joint  infection,  percentage 

of  bovine  and  human,  i.  58 
Bones,  tuberculosis  of,  i.  106 
Bonney,  value  of  X-ray  in  diagnosis, 

i.  519 
Bonniger,  describes  lymph  stasis  over 

pleurisy,  ii.  60 
Bouillon  Filtrate    (B.   F.)    Denys,  ii. 

354 
Bovine  and  human  infection,  relative 

proportion  of,  i.  60 
Bovine  bacilli  enter  body  same  as  hu- 
man, i.  62 
Bovine  infection,  ii.  514 

cannot  be   differentiated   clinically, 

i.   61,  63 
distribution  of,  i.  58 
largely  confined  to  childhood,  i.  58, 

59 
prevalence   of,   i.   57 
Bovine  tuberculin,  ii.  356 


662 


INDEX 


Bowditch,  value  of  x-ray  in  diagnosis, 

i.  519 
Brain,  effect  of  bombardment  of,  with 
toxins,  ii.  393 
tuberculous  ulceration  of,  ii.  189 
Brain   cells,  degenerated  in   tubercu- 
losis, i.  160 
Brannan   establishes    "Sea   Breeze", 

ii.  268 
Brauer  and  Spengler,  artificial  pneu- 
mothorax, ii.  429 
Breathing,   abdominal,  makes  auscul- 
tation difficult,  i.  428 
amphoric,  over  cavity,  i.  492 
deep,  and  prevention  of  tuberculo- 
sis, ii.  305 
favors  bronchogenic  infection,  i. 

37,  452 ;  ii.  306 
hastens  circulation,  ii.  306 
harsh,  in  advanced  tuberculosis,  i. 
479 
in  early  pulmonary  tuberculosis, 
i.  433 
impeded,  in  early  pulmonary  tuber- 
culosis, i.  431 
method  of,   during   auscultation,  i. 

428 
rough,  in  advanced  tuberculosis,  i. 
479 
in  early  pulmonary  tuberculosis, 

i.  430 
muscle  element  in,  i.  479 
thoracic,   due  to   assuming   erect 
position,  i.  128 
weak,  in  early  pulmonary  tubercu- 
losis, i.  430 
Brehmer,  and  curability  of  tuberculo- 
sis, ii.  190 
establishes    hygienic-dietetic    treat- 
ment of  tuberculosis,  ii.  190 
exercise  in  treatment  of  tuberculo- 
sis, ii.  282 
Bromide  in  treatment,  ii.  468 

tuberculous  meningitis,  ii.  91 
Bronchial    secretion    in    anaphylaxis, 

ii.  159 
Bronchial   spasm   in   anaphylaxis,   ii. 

159 
Bronchiectasis,    bacilli    rarely    found 
in,  ii.  588 
differentiated     from     tuberculosis, 
i.  614 
Bronchitis,     an     air-borne     infection, 
differs  from  tuberculosis,   i. 
67 


Bronchitis — Cont  'd 

and   early   clinical   tuberculosis,   i. 

364,  390 

as  cause  of  asthma,  ii.  164 

as  early  symptom   of  tuberculosis, 

cases    illustrating,    ii.     537, 

579,  582,  600,  603,  625,  632 

chronic      purulent,      differentiated 

from  tuberculosis,  i.  614 
differentiated  from  tuberculosis,  i. 

613 
in  advanced  tuberculosis,  i.  460 
influence  of  fog  on,  ii.  267 
Bronchitis,  symptom  of  active  tuber- 
culosis, case  illustrating,   ii. 
563 
tuberculous,  ii.  527 
Bronchogenous  metastasis,  i.   37 
Brown,  tuberculin  book  devised  by,  ii. 

382 
Browning,  study  of  relationship  of  cli- 
mate and  meteorological  in- 
fluences   on    hemorrhage,    ii. 
170 
Bruits,  heart,  i.  244 

C 

Cajal,  Eaymon  Y.,  on  similarity  of 
action  between  sympathetic, 
spinal  and  cerebral  nervous 
systems,  i.  191 

California,  Southern,  climate  of  foot 
hills  of,  ii.  255,  275 

Calmette,    artificial  immunization,   ii. 
335 
conjunctival  tuberculin  test,  i.  502, 

515 
feeding  experiments,  i.  69 

Cannon,  emotions  and  peristalsis,  i. 
279 

Capps,  study  of  diaphragmatic  pleu- 
risy, ii.  68 

Carbon  dioxide,  deleterious  influence 
of  excess  of,  not  proved,  ii. 
230 

Carr,  statistics  of  glandular  tubercu- 
losis in  childhood,  i.  113 

Case  illustrating,  acute  caseous  tuber- 
culosis, ii.  621 
careful  inspection  in  advanced  tu- 
berculosis, i.  469,  470 
chronic  caseofibrous  tuberculosis,  ii. 
553,  599,  609,  650,  659 


INDEX 


663 


Case  illustrating — Cont'd 

chronic     fibrocaseous      tuberculosis 
with  marked  contraction,  ii. 
590 
chronic   .fibroid    tuberculosis     with 

neurasthenia,  ii.   524 

chronic  fibrosis,  ii.  579,  631,  659 

comparative  results  of  examination 

by    stereoscopic     plate     and 

physical  examination,  i.  526 

extensive   fibrocaseous   tuberculosis, 

ii.  566 
marked    compensatory    changes,    i. 

308 
moderately  advanced  pulmonary  tu- 
berculosis with  slight  casea- 
tion, ii.  534 
rapidly  forming  fibrosis  with  lim- 
ited necrosis,  ii.  542 
recurrent  pneumothorax,  ii.  85 
traumatic  tuberculosis,  i.  315,  316 
tuberculous   meningitis,   ii.    94 
value  of  spasm  and  degeneration  in 
diagnosis,  i.  400 
Caseous    tuberculosis,    characteristics 

of,  i.  41 
Cathartics,  evil  effects  of,  i.  269 
Cavity,    amphoric    breathing    over,    i. 
492 
blowing  expiration  over,  i.  492 
cracked  pot  sound  over,  i.  491 
formation  of,  i.  28 
healing  of,  shown  at  autopsy,  ii.  597 
Cavity,  hemorrhage  from  tiny  vessels 
in,  ii.  173 
in  pulmonary  tuberculosis,  i.  489 
pain  when  forming,  i.  453 
pitch  of,  expiratory  low,  i.  479 
walls  of,  insensitive,  i.  451 
Cavity  changes  on,  auscultation,  i.  491 
inspection,  i.  489 
palpation,  i.  490 
percussion,  i.  490 
Cell  activity,  all,  under  nerve  control, 

ii.  390 
Cell    sensitization,    degree    of,    shown 
by    character    of    tuberculin 
reaction,  i.  504 
Cell  sensitization  prevents  metastases, 

i.  34,  119 
Cells,    body,    produce    defensive    fer- 
ments, ii.  197 
difference  in  behavior,  in  primary 
and   secondary  infections,  i. 
82,  84 
epithelial,  in  sputum,  i.  536 


Cells—Cont'd 

nerve,  injured  by  toxins,  ii.  392 
of  entire  body,  sensitized  in  tuber- 
culosis, ii.  337 
protective  properties  of,  vary  at  dif- 
ferent times,  i.  108 
sensitization    of,    effects    implanta- 
tion, i.  34 
changes  character  of  metastases, 

i.  63,  82 
shows  in   tuberculin  reaction,   i. 

504 
throughout  body,  ii.  342 
wandering,  carry  infection,  i.  36 
Cellular      activities,      controlled      by 
chemico-physical,     sensorimo- 
tor, and  psychical  influences, 
i.  168 
Centrifuge  for  determining  sediment 

volume  in  sputum,  i.  537 
Chest,  conditions  within,  which  alter 
percussion  note,  i.  425 
difference  in,  of  child  and  adult,  i. 

126 
important    anatomical    and  physio- 
logical facts  in  examination 
of,  i.  319 
light  percussion  stroke  felt  through, 
i,  418 
Chest    wall,    altered    contour,    in    ad- 
vanced tuberculosis,  i.  468 
altered  movement  of,  in  advanced 

tuberculosis,  i.  468 
bulging    of,    in   advanced   tubercu- 
losis, i.  469 
flattening  of  in  advanced  tubercu- 
losis, i.  469 
movement  of,  lessened  on  affected 

side,  i.  37 
projection  of  lung  on  anterior  sur- 
face of,  i.  319 
Chests,  do  not  depart  from  normal  in 

type,  i.  471 
Child,  effect  of  infection  upon,  i.  108 
gradually  develops  cellular  defense, 

i.  34 
greatest  danger  of  infection  during 

early  years,  i.  97;  ii.  504 
infection  of,  i.  95,  100;  ii.  503 
lacks  cell  sensitization,  i.  34,  96 
natural  defense  of,  i.  93 
protective  role  of  lymphatics  in,  i. 

93;  ii.  505 
specific  defense  increases  with  age 

of,  i.  95;  ii.  199 
what  predisposes,  to  infection,  i.  99 


664 


INDEX 


Childhood,    fate    of   infections   in,    i. 
107 
lymphatic   disease  of,   and  clinical 

tuberculosis  in  adult,  i.  70 
lymphatics  peculiar  in,  i.  31 
Children,  country  and  infection,  i.  79 
frequency  of  infection  in,  i.  100 
in  tuberculous  families  have  great- 
er immunity,  i.  363 
of  tuberculous    families,    infection 

in,  i.  362 
seaside  sanatoria  for,  ii.  267 
time  of  primary  infection,  i.  95 
yield  readily  to  treatment,  i.  Ill 
Chilliness  or  rigor,  part  of  syndrome 

of  toxemia,  ii.   110 
Chilling,  and  ventilation  of  skin,  ii. 

251 
Chloroform,     dissolves     interbacillary 
wax    and    distributes    bacilli 
that  are  bunched,  i.   549 
Chromaffin    system,    part    of    sympa- 
thetic, i.  173 
Chronic  fibrosis,  relationship  to  tuber- 
culosis, i.  615 
Ciliary  body,  innervation  of,  i.  176 
Ciliary  muscle,  innervation  of,  i.  176 
Circulation,   and   nutrition,   ii.   328 
efficiency  of,  reduced  by  deficiency 

of  inspiratory  act,  ii.  289 
factors  hindering  in  tuberculosis,  i. 

234 
factors  reducing  efficiency  of  in  tu- 
berculosis, ii.  289 
hastened  by  deep  breathing,  ii.  306 
influence   of  inspiratory   act   in,   i. 

301 
pulmonary,  i.  234 

effects  of  obstructing,  i.  235 
Circulatory  disturbances  in  advanced 

tuberculosis,  i.  442 
Circulatory  stimulation    in   treatment 

of  hemorrhage,  ii.  179 
Circulatorv  system,  and  prognosis,  i. 
6*38 
in  tuberculosis,  i.  230 
physiological    facts    concerning,    i. 
234 
City  air,  ii.  264 

Classification,     etiological,     of     early 
symptoms,  i.  365 
of  physical  changes  in  early  tuber- 
culosis, i.  394 
Cleaves,  physical  condition  of  sun,  ii. 
414 


Climate,  ii.   254 

and  prognosis,  i.  647 

bad,  physiological  influence  of,  ii. 

261 
cold,  requires  food,  ii.  273 
cold  dry,  effect  of,  ii.  268 
cold  moist,  effect  of,  ii.  269 
discussion  of,  partisan,  ii.  261 
dry,  gives  wide  diurnal  variation  in 

temperature,  ii.  269 
dry  low   land,   ii.    269 
dry  sunny,  irritates  nervous  system, 

ii.  270 
factors  in,  ii.  262 
factors  of,  applied  to  different  sec- 
tions   of    United    States,   ii. 
269 
factors  which  produce  varied  influ- 
ences of,  ii.  268 
hot,  dry,  effect  of,  ii.  268 
hot,  moist,  effect  of,  ii.  268 
important  in  all  diseases,  ii.  254 
influence  of  wind  in,  ii.  268 
inland,  in  therapeutics  of  tubercu- 
losis, ii.  268 
man's   power   of   physiological  ad- 
justment to,  ii.  257 
moist  low  land,  ii.  269 
mountain,  ii.  270 

mountain,   stimulating  to   metabol- 
ism, ii.  270 
of  Southern  California,  ii.  255 
remnant  of  let  alone  policy,  ii.  254 
Clinical   history,  i.    363 

importance  of  in  diagnosis,  i.  603 
Clinical  symptoms,  meaning  of,  i.  86 
Clinical  tuberculosis,  definition  of,  i. 
358 
relationship  of,  to  primary  metas- 
tases, i.  85 
Clothing,  effect  on  stagnation  of  body 
heat,  ii.  246 
for  the  tuberculous,  ii.  250 
Cloudy  swelling,  i.  44 
Coccidiodal    granuloma   differentiated 

from  tuberculosis,  i.  621 
Codein  for  relief  of  pain,  ii.  457 

in  cough,  ii.  447 
Cod  liver  oil  in  treatment,  ii.  467 
Cohnheim,    discussion   on  changes   of 
blood  at  altitude,  ii.  259 
discussion  on  relationship  of  food 
intake  to  exercise,  ii.  280 
Coin  sound  in  pneumothorax,  ii.   81 
Cold  compress  in  cough,  ii.  448 


INDEX 


665 


"Colds,"  as  early  symptoms  of  tu- 
berculosis, cases  illustrating, 
ii.   537,   542,   566,  570,   582, 
600,  603,  621,  625,  650,  653 
due  to  tuberculosis,  ii.  527 
frequent     and    protracted    in    ad- 
vanced, i.  460 
in  early  tuberculosis,  i.  390 
tuberculous,  accompanied   by  toxic 

symptoms,  i.  607 
when  present,  i.  607 
Cole,  Gregory,  value  of  x-ray  in  diag- 
nosis,   i.    518 
Colitis,  produced  by  raw  eggs,  ii.  326 
Collapse  in  anaphylaxis,  ii.  160 
Colon,    removal    of,    for    tuberculous 
enteritis,  case  illustrating,  ii. 
654  , 

tuberculosis  of,  statistics  of,  ii.  36 
Colonic    injections   in   entercolitis,    i. 

265 
Compensatory   changes,  between  tho- 
racic and  abdominal  cavities, 
case  illustrating,  ii.  598 
between    thorax    and    abdomen,    i. 

295 
case  illustrating,  marked,  i.   308 
in  pulmonary  tuberculosis,  i.  281 
within  thorax,  case  illustrating,  ii. 
597 
Compensatory      disturbances,      treat- 
ment of,  i.  311 
Compensatorv  emphysema,  caused  by, 

i.  284 
Congestion,  venous,  cause  of,  i.  44 
Consciousness,  loss  of,  in  pneumotho- 
rax, ii.  79 
Constipation,     atonic,     characteristics 
of,  i.  271 
treatment  of,  i.  271   , 
factors  favoring,  in  tuberculosis,  i. 

269 
spastic  and  atonic,  i.  270 
spastic,  characteristics  of,  i.  275 
treatment  of,  i.  275 
Consumption,  galloping,  i.  41 
Cook  and  Vander  Veer,  show  inher- 
ited condition  in  hay  fever, 
ii.  162 
Coplin,   pathology  of   changes  in  in- 
tercostal muscles  in  pleurisy, 
ii.  61 
Cornet,  experiments  in  inhalation  tu- 
berculosis, i.  66 
Cough,  and  posture,  i.  451 
as  early  symptom,  i.  386 


Cough — Cont  'd 
cause  of,  ii.  445 

causes  marked  rise  in  temperature, 
case  illustrating,  ii.   616 
Cough,  depending  on  overflowing  of 
cavities,  i.  451 
due  to  extreme  traction  on  vagus, 

case  illustrating,  ii.  646 
due  to  laryngeal  irritation,  ii.  448 
effect  of,  deleterious,  ii.  446 
on  temperature,  case  illustrating, 

ii.  645 
rest  upon,  ii.  291 
favors    bronchogenic    infection,    i. 

37,  452 
in  advanced  tuberculosis,  i.  45  , 
increases  temperature,  ii.  573 
injury  to  the  lung  following,  ii.  292 
in  tuberculous  laryngitis,  i.  26 
much,  can  be  avoided,  ii.  446 
treatment  of,  ii.  447 
unnecessary,   should  be  avoided,  i. 

452 
wet  jacket  in  treatment  of,  ii.  411 
Country  air,  ii.  264 
Covering,  excessive,  effect  on  temper- 
ature, ii.  155 
Cracked  pot  sound  over  cavity,  i.  491 
Creosote  in  treatment,  of   cough,   ii. 
448 
of  tuberculosis,  ii.  463 
Crile,  fever  part  of  kinetic  drive,  ii. 
117 
kinetic  system  in  defense,  i.  219 
on  mechanism  of  fever  production, 
i.  372 
Croquet,  a  suitable  game,  ii.  299 
Cytological  examination  of  sputum,  i. 
536  i 


D 


Da  Costa,  D.  C,  Jr.,  dorsal  percus- 
sion in  mediastinal  thicken- 
ing, i.  501 
De  la  Camp,  cause  of  trunk  shadows 

in  lung  plate,  i.  522 
Defense,  natural,  of  little  child,  i.  93 
specific,  broken  down  by,  i.  107 
cellular,  and  infection,  i.  34,  64, 

89,  112 
commensurate  with  severity  of  in- 
fection, i.  600 
determines    nature    of    lesion,    i. 
63,  359 


666 


INDEX 


Defense,  specific — Cont  'd 

developed  after  birth,  i.  82;   ii. 

196 
gradual  development  of  in  child, 

i.  34,  63;  ii.  194 
increases   with   age   of    child,  ii. 

199 
prevents  spread  of  disease,  i.  120; 
ii.  198 
Degeneration,  amyloid,  i.  43 
cause  of,  i.  43 
fatty,  i.  44 

general,  of  muscles,  skin  and  sub- 
cutaneous tissue,  i.  467,  474 
pathological,    of    internal    viscera, 
possibly  due  to  reflex  nerve 
stimulation,  i.  606 
regional,  of  muscles,  skin  and  sub- 
cutaneous tissue,  i.  179,  399, 
405,  466 
Deglutition,    painful,    in    tuberculous 
laryngitis,  ii.  26 

Density  of  tissues  determined  by  pal- 

"'  pation,  i.  476 
Depressive  emotions  and  fever,  ii.  108 
relieved  by  psychotherapy,  ii.    389 
D'Espine's  sign,  i.  115 
Dettweiler  and  rest  in  treatment  of 

tuberculosis,  ii.  282 
Diagnosis,  and  differential  of  tuber- 
culosis, i.  596,  612 
cases    illustrating    comparative    re- 
sults  of  x-ray   and  physical 
examination,  i.  526 
clinical,  i.  360 

relationship   to   infection,   i.   359 
clinical  history  in,  i.  363,  603 
condition     of     muscles    and    sub- 
cutaneous  tissue   in,  i.    405, 
410,  412,  466 
deceptive  not  permissible,  ii.  213 
delayed,  case  illustrating,  ii.  661 
diaphragm    and    superficial    muscle 
reflexes,  value  of  in,  i.  399, 
468,  604 
differential,    between    tuberculosis, 
cancer  and  syphilis  of  larynx, 
ii,  27 
difficulties  of,  i.  597 
difficulty  of  patient  obtaining,  case 
illustrating,  ii.  557,  582,  583 
dilatation  of  pupil  in,  i.  402 
early,  and  prognosis,  i.  642 

depends    on    accurate    conception 
of  pathology,  ii.  188 


Diagnosis,  early — Cont'd 
inspection  in,  i.  402 
of  tuberculosis,  meaning  of,  i.  357 
value  of  temperature  in,  i.  607 
x-ray  in,  i.  611 
examination  of,  blood  in,  i.  575 
feces  in,  i.  578 
sputum  in,  i.  534 
urine  in,  i.  568 
family  history  in,  i.  361 
hindered  by   long  held  pessimistic 

attitude,  i.  597 
importance   of,   altered   contour  of 
chest  wall  in,  i.  468 
altered  movement  of   chest  wall 

in,  i.  468 
careful,   in   advanced   pulmonary 

tuberculosis,  i.  435 
in  hidden  tuberculosis,  i.  596 
muscles  in,  i.  399,  422,  428,  477, 
535 
cases  illustrating,  ii.  525,  535, 
543,  554,  567,  580,  610,  622, 
633 
subcutaneous    tissue    in,    i.    398, 
410,  412,  422,  466,  498 
cases  illustrating,  ii.  525,  535, 
543,  554,  567,  580,  610,  622, 
633 
toxic   group   of   symptoms  in.   i. 

605 
trophic    changes    in   soft   tissues 
over  pleural  adhesions  in,  ii. 
60 
tuberculin  test  in,  i.  599 
laboratory  method  in,  i.  533 
lagging  in,  i.  403,  468 
made  by  correlation  of  data,  i.  602 
inspection    and    palpation,    cases 
illustrating,  ii.  526,  535,  543, 
555,  567,  601,  611,  622,  633, 
652 
no   stereotyped  way  of  making,  i. 

361 
not  made  when  bacilli  first  enter  tis- 
sue, i.  602 
of  active  glandular  tuberculosis,  i. 

114 
of  acute   serofibrinous   pleurisy,  ii. 

57 
of  pneumothorax,  ii.  81 
of  tuberculosis  of  bladder,  ii.  101 
of  tuberculous  laryngitis,  ii.  24 
of  tuberculous  meningitis,  ii.  91 
past  illness  in,  i.  364 
patient  should  be  told  of,  ii.  213 


INDEX 


667 


Diagnosis — Cont  'd 

percussion  in  early,  i.  417 
pulmonary,  method  of  using  x-ray 

in,  i.  524 
relative     importance     of     different 
groups    of    symptoms    in,    i. 
603 
should  not  depend  on  auscultation 

alone,  i.  427 
tuberculin  test  in,  i.  502 
conjunctival,  i.  515 
cutaneous,  i.  512 
intradermal,  i.  515 
percutaneous,  i.  515 
subcutaneous,  i.  506 
value  of,  changed  contour  in  trape- 
zius muscle  in,  i.  407 
lymphocytes  in  sputum,  i,  582 
palpation  in,  i.  409 
physical  examination  in,  i.  608 
symptoms     due     to     tuberculous 

processes  per  se  in,  ii.  537 
x-ray  in,  i.  516 
Diaphragm,  altered  position  and  func- 
tion of,  i.  282,  305 
changes  in  position  of,  in  pneumo- 
thorax, ii.  79 
factors  in  displacement  of,  i.  302 
Diaphragm,  importance  to  respiration, 
i.  296,  300,  325,  326 
innervation  of,  i.  296,  325,  331 
in   diagnosis    of   pulmonary   tuber- 
culosis, i.  401 
in  production  of  lagging,  i.  403,  468 
lessened  motion  of,  i.  301 
limited  motion  should  be  studied  on 
easy  respiration,  i.  525 
shown  by  x-ray,  i.  525 
marked  displacement  of,  case  illus- 
trating, ii.  595,  598 
motor  reflex  in  from  lung,  i.  403 
position  at  different  age  periods,  i. 

321 
reflex,  diagnostic  importance,  i.  604 
reflexly  stimulated,  causes  lagging 
of  chest  wall,  i.  403 
Diaphragmatic  pleurisy,  ii.  67 
Diarrhea,  in  anaphylaxis,  ii.  159 
not  always  accompanies  ulceration 

of  bowel,  i.  52 
often  absent  in  tuberculous  enteri- 
tis, case  illustrating,  ii.  644, 
1    648,  658 
tuberculous,  diet  in,  ii.  46 
hot  applications  in,  ii.  47 
opium  in,  ii.  47 


Diarrhea,  tuberculous — Cont  'd 

pharmacopeial  remedies  in,  ii.  47 
rest  in,  ii.  46 
Diazo  reaction  and  prognosis,  i.  639 
case  illustrating,  ii.  618 
formula  for  making,  i.  569 
method  of  recording,  i.  569 
Diet,  errors  in,  i.  280 
in  hemorrhage,  ii.  181 
rational,  ii.  315 

relation  of,  to  nutrition,  ii.  308 
Digestion  and  harmone  theory,  i.  257 
improved  by  psychotherapy,  ii.  394 
in  stomach,   disturbed  by  colloidal 
solution,  i.  256 
Digestive   disturbances,   in    advanced 
tuberculosis,  i.  439 
part   of    syndrome    of   toxemia,   ii. 
110 
Digestive    system,    and    prognosis,    i. 
637 
in  tuberculosis,  i.  251 
reflex  disturbances,  in  early  tuber- 
culosis, i.  388 
Dillingham,  conservative  treatment  of 
genitourinary  tuberculosis,  ii. 
100 
Discontent,  effect  of,  on  temperature 

curve,  ii.  146 
Discouragement,  effect  of  on  tempera- 
ture curve,  ii.  146 
Disposition  to  tuberculosis,  i.  117 
Double  personality  in  tuberculosis,  i. 

50 
Dover's  powder  in  treatment  of  pain, 

ii.  457 
Droplet  infection,  i.  68;  ii.  513 
Dunham,    normal    trunk    shadows    in 

plate,  i.  522,  523 
Dupre,    pathology   of    psychoses    and 

psychoneuroses,  i.  159 
Dust  as  cause  of,  asthma,  ii.  164 

infection,  ii.  512 
Dyspnea,  due  to  fat  flabby  condition, 
ii.  293 
in  advanced  tuberculosis,  i.  457 
in   pneumothorax,    ii.    75 
measures  for  relief  of,  i.  458 
rest  when  present,  ii.  292 
Dyschezia,    (Hertz),   i.   273 


E 


Ear,   tuberculosis   of,  ii.   106 
Eastwood  shows  percentage  of  bovine 
and  human  infections,  i.  59 


668 


INDEX 


Eating,  practical  method  for  encour- 
agement of,  ii.  314 
Economic  status  in  prognosis,  i.  626 
Effusion,  pleural,  shall  it  be  removed, 
ii.  5 
tuberculin  aids  in  absorption  of, 
ii.  59 
Eggs,  raw,  limitation  of,  as  food,  ii. 
324 
produce  colitis,  ii.  326 
Ellermann  and  Erlandsen,  technic  for 
examination    of    sputum,    i. 
551,    555 
Elliot,  internal  secretions,  i.   169 
Embolism,  gas,  during  artificial  pneu- 
mothorax, ii.  441 
Emotions,  depressive,  act  centrally,  i. 
223 
act  on  sympathetic,  i.  189 
cause  loss  of  weight,  i.  441 
cause  rise  of  temperature,  ii.  146 
effect  of,  i.   223,   224,   228,  279, 

367;  ii.  389 
symptoms  due  to,  i.  189 
effect  of,  on  gastrointestinal  tract, 

i.  279 
helpful  and  harmful  act  differently, 
ii.  394 
Emphysema,  compensatory,  and  arti- 
ficial  pneumothorax,  ii.   431 
auscultation  in,  i.  495 
changes  in  contour  of  chest  in,  i. 

494 
changes  in  motion  of  chest  wall 

in,  i.  494 
how  produced,  i.  284 
inspection  in,  i.  494 
marked,  cases  illustrating,  ii.  594, 

597 
palpation  in,  i.  495 
percussion  in,  i.   495 
respiratory  note  in,  i.  478 
roughened  respiratory  note  in,  i. 
495 
Emphysema   of   superficial   structures 
in  artificial  pneumothorax,  ii. 
441 
Endurance,  lack  of,  part  of  syndrome 
of  toxemia,  ii.  110 
loss  of,  in  advanced  tuberculosis,  i. 
438 
Enema,  in  relief  of  loaded  colon,  i. 

274 
Enterocolitis  in  tuberculosis,  i.  264 
symptoms  of,  i.  264 
treatment  of,  i.  264 


Enteritis,  tuberculous,   ii.   33 

a  surface  infection,  i.  53,  90;  ii. 
33 

bacilli  in  stool  in,  ii.  41 

cathartics  to  be  avoided  in,  ii.  45 

change  in  motility  in,  i.  52 ;  ii.  40 

development  of,  cases  illustrat- 
ing, ii.  618,  654 

diet  in,  ii.  46 

enemas  in,  ii.  47 

factors  predisposing  to,  i.  51,  90 ; 
ii.  35 

found  at  operation,  case  illustrat- 
ing, ii.  643 

frequency  of,  ii.  33 

hemorrhage  in,  ii.  38 

hot  applications  in,  ii.  47 

local  irritations,  predisposing 
factors  in,  ii.  36 

lymph  glands  not  common  infec- 
tion in,  i.  83 

metastatic,  ii.  34 

muscle  reflex  in,  ii.  43 

nausea  in,  ii.  39 

not  recognizable  by  symptoms, 
cases  illustrating,  ii.  644, 
657 

nutritional  changes  in,  ii.  39 

operation  for,  case  illustrating, 
ii.  593 

operative  measure  in,  ii.  44 

pain  in,  ii.  40 

pathology  of,  i.  51 ;   ii.  37 

perferation  of  intestine  in,  case 
illustrating,  ii.  661 

pulse  in,  ii.  42 

reflex  trophic  changes  as  predis- 
posing factor  in,  ii.  37 

rest  in,  ii.  46 

retardation  of  intestinal  contents 
favors,  ii.  35 

slow  pulse  in,  case  illustrating, 
ii.  658 

stool  in,  ii.  41 

stricture  in,  ii.  38 

symptoms  of,  ii.  39 

temperature  in,  ii.  42 

treatment  of,  ii.  44 

pain    in,    case    illustrating,    ii. 
648 

usually  secondary,  ii.  35 

variable  appetite  in,  ii.  39 
Environment  in  prognosis,  i.  626 
Enzymes,    cells    stimulated,    produce 
specific,  i.  95 


INDEX 


669 


Enzymes — Cont  'd 

specific  proteolytic,  split  up  tuber- 
culin, ii.  351 
Esophagus  reflex,  ii.  647 
Evans,  graphic  temperature  chart  used 

by,  i.  381 
Examination,  advantages  of  method- 
ical, i.  395 
of    chest,    fluoroscopic,    importance 

of,  i.  611 
of  sputum,  cytological,  i.  536 
physical,    altered    by    condition    of 
muscles,  i.  332,  398 
subcutaneous  tissue,  i.  398 
and  tuberculin  therapy,  ii.  382 
and  x-ray,   relative   value   of,  i. 

516 
cases    illustrating,    ii.    525,    535, 
543,  554,  567,  580,  591,  600, 
610,  622,  632,  651 
daylight  preferable  for  i.  395 
difficult,  i.  608 
etiological         classification        of 

changes  in,  i.  396 
favorable  conditions  for,  i.  394 
in  advanced  tuberculosis,  i.  464 
value  of,  in  diagnosis,  i.  608 
sitting  posture  best  for,  i.  395 
Excavation,  areas  of,  marked  by  per- 
sistent  rales,   i.  481 
Excitement,  effect  of,  on  temperature 

curve,  ii.  146 
Exercise,  and  autoinoculation,  ii.  203 
calls  for  increased  food  intake,  ii. 

280 
cause    of    more    deaths    than    any 

other  measure,  ii.  298 
caution  in  prescribing,  ii.  297 
effects  of,  ii.  295 

on  temperature  curve,  ii.  148 
upon  the  heart,  ii.  289 
essential  to  highest  state  of  health, 

ii.  283 
for  lung,  ii.  204 

graduated,  in  tuberculosis,  ii.   301 
in    early    afebrile    tuberculosis,    ii. 

284 
in  treatment  of,  congestive  hemor- 
rhage,  ii.    180 
tuberculosis,  ii.  282 
in  tuberculosis,  ii.  277 
increases  toxemia,  ii.  284 
indication  for,  ii.  295 
individualization  in  use  of,  ii.  286 


Exercise — Cont  'd 

method    of    instituting,    case    illus- 
trating, ii.  546,  548 
not   based  on   degrees   of   temper- 
ature, ii.  297 
not  taken  before  meals,  ii.  296 
physiology  of,  ii.  277 
stimulates  circulatory  and  respira- 
tory system,  ii.  278 
stimulates  heat  production,  ii.  278 
suitable  for  the  tuberculous,  ii.  298 
technic  of  applying,  ii.  295 
walking   best,    for    tuberculous,    ii. 
299 
Exertion  increases  dyspnea,  i.  457 
Expiration  prolonged  by  infiltration, 
i.  478 
emphysema,  i.  478 
Exudate  in  tuberculous  meningitis,  ii. 

88 
Exudates,    pleural,    absorption    of,    i. 

49 
Eye,  symptoms  in  tuberculous  menin- 
gitis, ii.  90 

F 

Face,   flushing  of,   in  early  tubercu- 
losis, i.  389 
Fallopian   tubes,   tuberculosis    of,   ii. 

103 
Family,  instruction  of,  importance  of, 

ii.  472 
Family  history,  i.  361 

meaning  of  open  tuberculosis  in,  i. 
262 
Fanning,  standard  diet  for  tubercu- 
losis, ii.  316 
Fat,  to  be  avoided,  ii.  312 
Fat   people,  not   necessarily  healthy, 

ii.  312 
Fatty  degeneration,  i.  44 
Feces,  bacilli  in,  i.  578 ;  ii.  513 

does  not  mean  bowel  infection,  i. 

579 
when  no  sputum  raised,  i.  580 
examination  of  for  occult  blood,  i. 

5.80 
in  tuberculosis,  i.  578 
frequency  of  bacilli  in,  i.  579 
Feet,   cold,   cause   of   and  relief  for, 

ii.  251 
Fenwick    and    Dodwell,    statistics    of 

colon  infection,  ii.  36 
Fermentation,   method    of    examining 
sputum,  i.  553 


670 


INDEX 


Ferments,  digestive  protective  action 

of,  i.  251 
Fever,  absence  of,  does  not  mean  ab- 
sence   of    clinical    tuberculo- 
sis, i.  373,  378 
a  conservative  process,  ii.  121 
an  index  of  degree  of  toxemia,  ii. 

129 
air  baths  in,  ii.  455 
and  depressive  emotions,  ii.   108 
and  heat  elimination,  ii.  123 
and  heat  formation,  ii.  123 
beneficial  influences  of,  ii.  453 
cannot  be  prevented  when  activity 
present,  case  illustrating,  ii. 
641 
caused  by  bacilli  gaining  access  to 

blood  stream,  ii.  156 
caused  by  depressive    emotions,    ii. 

146 
cause  of,  ii.  108 

in  early  tuberculosis,   ii.   126 
in  tuberculosis,  ii.  122,  286 
central  nerve  stimulation  in,  ii.  109 
charts  of  common  type  in  advanced 

tuberculosis,  i.  447 
contributions  to  study  of,  ii.  113 
diurnal  variation  in,   ii.   109 
effects  of,  confused  with  effects  of 

toxemia,   ii.    452 
experimental,  heat  production  and 

loss  in,  ii.  112 
favors  antibody  formation,  ii.  118 
in  advanced  tuberculosis,  i.  445 
integral  part  of  syndrome  of  tox- 
emia, ii.  116 
interferes   with   growth   of    bacilli, 

ii.  118 
in  tuberculosis,  meaning  of,  ii.  108 
mixed  infection  not  cause  of,  ii.  122 
part  of  body  defense,  ii.  117 
part   of    syndrome   of   toxemia,   ii. 

108,  110,  452 
physiological,  ii.  114 
prevents  multiplication  of  bacteria, 

i.  373  | 

produces  cellular  change,  ii.  118 
production  of,  ii.  285 
protein  as  cause  of,  ii.  114,  116 

discussion  of,  ii.   118 
relation  to  nervous  system,  ii.  108 
rest  during,  ii.  285 
rest  in  bed  in  treatment  of,  ii.  454 
result  of  deficient  heat  elimination, 
ii.  117 


Fever — Cont  'd 

result  of  increased  heat  production, 
ii.  117 
Fever,  sympathetic  stimulation  in,  ii. 
110 
treatment  of,  ii.  452 
vasoconstriction  of  skin  vessels  in, 
ii.  108 
Fibrocaseous    tuberculosis,    character- 
istics of,  i.  41 
Fibroid     tuberculosis,     characteristics 
of,  i.  40 
in  prognosis,  i.  629 
Fibrosis,  gradual  formation  of,  cases 
illustrating,  ii.   553,   594 
in  pulmonary  tuberculosis,  i.  489 
may    be    extensive    without    bacilli 

being  found,  ii.  588 
ultimately   takes   on  necrosis,   case 

illustrating,  ii.  606 
usually  overlooked  on  examination, 
ii.  558 
Fibro-ulceration  tuberculosis,  temper- 
ature curve  in,  ii.  129 
Finsen,  popularizes  light  therapy,  ii. 

422 
Fischberg,  beneficial  effect  of  artifi- 
cial pneumothorax,  ii.  433 
statistics  of  infection  in  childhood, 
i.  102 
in  tuberculous  and  non-tubercul- 
ous families,  i.  103 
Fistula,  in  ano,  relation  of,  to  pulmo- 
nary   tuberculosis,    eases    il- 
lustrating, ii.    653,   656 
should     not     be     operated     during 
active   pulmonary   tuberculo- 
sis, cases  illustrating,  ii.  653, 
656 
Fliigge,    droplet    infection,    i.    68 
Fluoroscope,  use  of,  to  guide  site  of 
puncture    in    artificial   pneu- 
mothorax, ii.  436 
Fly  as  carrier  of  bacilli,  i.  78 
Foci,    metastatic,    small,    produce    no 
symptoms,  ii.  192 
of   tuberculosis,   stimulated  by   tu- 
berculin, ii.  332 
pulmonary,  distribution   of,  i.   125 
Focus,  hidden,  dangerous,  i.  599 
primary,    and    primary    metastatic, 
method  of  differentiating,  i. 
82 
primary  lung  focus,  i.  66,  82 
tuberculous,  activity  in,  case  illus- 
trating, ii.  572 


INDEX 


671 


Fog,  and  open  air,  ii.  252 
increases  bronchitis,  ii.  267 
produces  chill,  ii.   267 
Food,  ii.  308 

amounts   of,  on  rest   and   exercise, 
ii.   318 
required,  vary  according  to  condi- 
tion, ii.  321 
and  prognosis,  i.  649 
j    increased  amounts  required  for  ex- 
ercise, ii.  280 
open  air  causes  greater  demand  for, 

ii.  248 
suited  to   digestive  powers   of  pa- 
tient, ii.  327 
type   of,  in  atonic  constipation,  i. 

271 
value  of,  cereals,  ii.  320 
fats,  ii.  320 
fruits,  ii.  319 

household  measures  of,  ii.   322 
meat  and  milk  products,  ii.  319 
raw  eggs,  ii.   324 
Foods,  allowed  in  entercolitis,  i.  266 
caloric  value  of,  ii.   316 
easily  digested,  ii.  308 
forbidden  in  entercolitis,  i.  266 
Foot  bath,  importance  of,  ii.  412 
Forest,  psychological  effect  of,  ii.  263 
Forlanini,  artificial  pneumothorax,  ii. 

429 
Freund's  theory  critically  examined, 

i.  135 
Freund's  theory  of  shortening  of  first 
rib   and   ossification   of   first 
costal  cartilages,  i.  133 
Friedberger  and  Mita,  studies  in  ana- 
phylaxis, ii.  344 
and  tuberculin  reaction,  ii.  336 
Functional  activity,  normal  variation 

in,  i.  334 
Furniture  should  be  simple,  ii.  511 

G 

Games  in  tuberculosis,  ii.  298,  301 

Ganglia,  of  sympathetic  system,  i.  172 
sympathetic,  can  reflexes  take  place 

in,  i.  191 
sympathetic,  question   whether   im- 
pulse interrupted  in,  i.  190 

Gas,    amount    injected    in    artificial 
pneumothorax,  ii.  436 

Gaskell,   involuntary  nervous   system, 
i.  169 

Gastrointestinal,      symptoms      during 
toxemia,  i.  270 


Gastrointestinal  tract,  effect  of  emo- 
tions on,  i.  279 
in  tuberculous  meningitis,  ii.  90 
nervous  influences  in,  i.  278 
reflex   disturbances  of,   from  lung, 
i.  253 
Generative    organs,    muscles   of,   sup- 
plied by  sympathetics,  i.  176 
Genitourinary     infection,     percentage 
of,  human  and  bovine,  i.  59 
Genitourinary  system,  tuberculosis  of, 

ii.,96 
Ghon,  primary  lung  foci  of,  may  be 
intestinal  infections,  ii.  34 
focus,  i.  66 
pulmonary      foci       and      regional 

lymphatic  glands,  i.  30,  83 
statistics    showing    distribution    of 
pulmonary  foci,  i.  125 
Glands,  bronchial,  diagnosis  of  tuber- 
culosis in,  i.  114 
increased  activity  of,  during  infec- 
tion, i.  107 
infection  of  peritracheal  and  peri- 
bronchial, i.  32 
lymphatic,  bacilli  pass  through  in 
childhood,  i.   31 
protect    child    against    infection, 
ii.  196 
mediastinal,  infected  by  bacilli  in- 
jected into  rectum,  i.  30 
mesenteric,  infection  of,  case  illus- 
trating, ii.   658 
peribronchial,    projection    on    sur- 
face, i.  323 
regional,  markedly  involved  in  pri- 
mary infections,  i.  83 
not  markedly  involved  in  second- 
ary infection  of  lung,  larynx 
and  intestine,  i.  83 
tuberculosis   of,  i.   54,   112 
by  age  periods,  i.  113 
Glandular    infection,    relationship    to 
clinical  tuberculosis,  i.  87 
tuberculosis,  diagnosis  of,  i.  114 
Gley,  E.,  internal  secretions,  i.  159 
Goodbody,    Bardswell    and    Chapman, 
diets     for     tuberculous     pa- 
tients, ii.  315 
Graduated  exercise  in  tuberculosis,  ii. 

301 
Griffith    shows    percentage   of   bovine 
and  human  infections,  i.  58 
Gram-positive    but    non-acid-fast    ba- 
cilli, i.  559 
Graves,  scaphoid  scapula,  i.  471 


672 


INDEX 


H 

Habitus  phthisicus,  i.   147 
Hamburger,  primary  lung  focus,  i.  66 
statistics  of,  fatal  and  chronic  tu- 
berculosis by  age  periods,  i. 
97 
healing  by  age  periods,  i.  97 
infection  in  childhood,  i.  101 
mortality  by  age  periods,  i.  97 
Harbitz,  statistics  of  postmortem  tu- 
berculosis among  children,  i. 
101 
Hart's  statement  of  Freund's  theory, 

i.  135 
Hart's  statistics  of  healing  of  apical 
infections,    i.    Ill,    406;    ii. 
191 
Hay    fever,    due    to    anaphylaxis,    ii. 
157,  161 
inherited  vagotonia  in,  ii.  162 
Head,  emphasizes  sensory  disturbance 

of  skin,  i.  454 
Head's  zones,  i.  181 
Headache,  in  tuberculous  meningitis, 
ii.  89 
part   of   syndrome    of   toxemia,   ii. 
110 
Healing,  clinical  and  pathological,  not 
identical,     case     illustration, 
ii.  607 
depends   on  tuberculin,   ii.    333 
determined    by    disappearance     of 

muscle  spasm,  i.  411 
evidences  of,  in  clinical  tuberculo- 
sis, ii.  193 
important  principles  of,  ii.  192 
in   advanced   tuberculosis,   difficult, 

ii.  201 
in  tuberculosis,  why  aided  by  tu- 
berculin, ii.  348 
not  synonymous  with  cessation  of 

symptoms,  ii.  194 
occurs  in  extensive   active  lesions, 

case  illustrating,  ii.  575 
of  more  recent  tubercles  stimulated 

by  tuberculin,  ii.  349 
readily  produced  in  early  tuberculo- 
sis, ii.  200 
requires  long  time,  ii.  383,  564 
shown  at  autopsy,  ii.  594 
slowness   .of,    case    illustrating,    ii 

540,  563,  588 
spontaneous,  in  tuberculosis,  statis- 
tics of,  ii.  191,  193 
statistics  of,  by  age  periods,  i.  97 


Heart,  action  of,  improved  by  open 
air,  ii.  248 

clinical  evidence  of  failing,  i.  248 

condition  of,  calling  for  rest,  ii.  291 

death  from  dilatation  of,  ii.  574 

difficulty  in  examining,  in  tubercu- 
losis, i.  242 

dilated,  treatment  of,  case  illustrat- 
ing, ii.  605 

displacement   of,  i.   242,  282,  286, 
292 
cases  illustrating,  ii.  598,  613 
depends  on  size  of  pericardium, 

i.  286;  ii.  598 
effects  of,  i.  292 
in  pneumothorax,  ii.  80 
in  tuberculosis,  i.  283,  286,  288, 
291 

effect  of,  rest   and   exercise  upon, 
ii.  289 
tuberculosis  upon,  i.  236 

explanation  of  variability  in  action, 
i.  387 

failing,  treatment  of,  i.  249 

hypertrophy  of  right  ventricle  of, 
i.  240,  444 

importance  of  good,  i.  230 

in  advanced  tuberculosis,  i.  442 

in  pneumothorax,  ii.   78 

in  prognosis,  i.  443 

marked  displacement  of,  to  right, 
ii.  595,  597 

must  be  carefully  guarded  in  pul- 
monary tuberculosis,  ii.  289 

nervous  influence  upon,  i.  230 

organic  lesions  of,  and  tuberculosis, 
i.  243 

rapid,  part  of  syndrome  of  tox- 
emia, ii.  110 

reflex  disturbance  of,  in  early  tu- 
berculosis, i.  387 

reflexly  slowed  by  pulmonary  in- 
flammation, i.  231;  ii.  551 

reserve  power  of,  i.  307 

slowing  of,  showing  vagus  stimula- 
tion, case  illustrating,  ii.  618, 
629 

small,  cause  of,  i.  148,  149,  239, 
303,  444 

sudden  acceleration  of,  in  pneumo- 
thorax, ii.  82 

sympathetic  and  greater  vagus  ac- 
tion on,  i.  199;  ii.  110,  551 

sympathetic  stimulation,  case  illus- 
trating, ii.  618 


INDEX 


673 


Heart — Cont  'd 

terminal   dilatation   of,   case   illus- 
trating, ii.  629 
Heart  block,    partial,    case    illustrat- 
ing, ii.  572 
Heart  bruits,  i.  244 
Heart  displacement,   symptoms  of,  i. 
1 13,  292 
to  left,  i.  288 
to  right,  i.  291;  ii.  595 
Heart  murmur,    musical,    ease    illus- 
trating, ii.  602  j 
Heart  muscle,  degeneration  of,  i.  244 
Heart  strain,  case  illustrating,  ii.  594 
in  tuberculosis,  symptoms  of,  ii.  290 
Heat,  comparative   amounts  for  rest 
and  work,  ii.  279 
in  treatment  of  pain,  ii.  457 
reduced,  elimination  of,  largest  fac- 
tor  in   fever   production,   ii. 
122 
skin,  most  important  factor  in  regu- 
lating, ii.  403 
Heat  loss,  controlled  by  central  nerv- 
ous system,  ii.  115 
Heat  production  in   fever,   cause  of, 

,    ii.  113 
Heat  stagnation,  effects  of,  ii.  235 
Hectic  flush,  in  advanced  tuberculo- 
sis, i.  458 
sympathetic  and   greater  vagus  in 
production  of,  i.  199 
Heise  and  Sampson,  value  of  x-ray  in 

diagnosis,  i.  519 
Heliotherapy,  ii.  414 
and  prognosis,  i.  648 
case  illustrating  use  of,  ii.  548 
technic  of  applying,  ii.  424 
Hematogenous  infection,  i.  38 

accounts  for  metastases  in  distant 
organs,  i.  38 
Hematogenous    metastases,    mild    be- 
cause   of    antibacillary    ele- 
ments in  blood,  i.  38,  64 
Hemorrhage,  a  sign  of  early  tubercu- 
losis, ii.   169,  542,  579,  609, 
622,  632 
a  symptom  due  to  tuberculous  proc- 
ess per  se,  ii.  164 
accompanies  necrosis  and  caseation, 

case  illustrating,  ii.  614 
aconite,   veratrum   viride,   pituitrin 
and  nitrites,  in  treatment  of, 
ii.  178 
amount  of,  ii.  168 


Hemorrhage — Cont  'd 

and  advanced  tuberculosis,  i.  461 
artificial    pneumothorax,    in    treat- 
ment of,  ii.  180 
attention  to  bowels  in,  ii.  182 
baths  during,  ii.  183 
cause  of,  ii.  168 
character  of,  in  infarct,  i.  616 
climatic    and    meteorological    influ- 
ence in  production  of,  ii.  170 
caused  by  arteries  resisting 
obliterating  effect  of  tuber- 
culosis, ii.  171 
coagulability  of  blood  in,  ii.  178 
complications  following,  ii.  183 
congestive  or  toxic  type,  ii.  174 
diet  in,  ii.  181 
does  not  indicate  patient  not  doing 

well,  ii.  577 
due  to  expulsion  of  necrotic  mass, 

ii.  172 
dry  weather  and,  ii.  170 
exercise  in  treatment  of  congestive, 

ii.  180 
foggy  weather  and,  ii.  170 
followed  by,   extension   of   disease, 
ii.  184 
miliary  tuberculosis,  ii.  184 
pneumonia,  ii.  177,  183 
severe  anemia,  ii.  172 
shock,  ii.  184 
follows  rapid  caseation,  case  illus- 
trating, ii.  626 
follows  swimming,  ii.  300 
frequency  varies  with  material,  ii. 

168 
from  cavity,  i.  28;   ii.  173 
importance    of    preserving    clot    in 

rupture  after,  ii.  175 
in   pulmonary   tuberculosis,   ii.    168 
in  tuberculous  enteritis,  ii.  38 
makes  diagnosis  of  tuberculosis  al- 
most certain,  i.  607 
may  come  any  time  prior  to  heal- 
ing, ii.  564 
mental  rest  in,  ii.  176 
morphine  in  treatment  of,  ii.  176 
not  beneficial  per  se,  ii.  184 
overexertion  as  cause  of,  ii.  168 
pharmacological  remedies  in,  ii.  177 
physical  rest  in,  ii.  177,  288 
pneumococcus  as  cause  of,  ii.  177 
prevention  of,  ii.  168 
rainy  weather  and,  ii.  170 
rarely  fatal,  ii.  181 
result  of,  ii.  184 


674 


INDEX 


Hemorrhage — Cont  'd 

severe,  due  to  aneurism  or  erosion 

of  vessel,  ii.  171 
treatment  of,  ii.  174 

by  concentrated  salt  solution,  ii. 

179 
case  illustrating,  ii.  617 
tuberculin  stopped  during,  ii.  182 
type  of,  treated  by  circulatory  stim- 
ulation, ii.  179 
Hemorrhages,    appear    in    groups,    ii. 
170 
differentiation  of  types,  difficult,  ii. 

174 
different  types   of,  explained,   case 

illustrating,  ii.  617 
types  of,  ii.  171 
Heroin  in  cough,  ii.  447 
Hertz,   cause   of   atonic   constipation, 
i.  272 
esophagus  reflex,  ii.  647 
Higier,   vegetative   and  visceral   neu- 
rology, i.  169 
Hill,  studies  on  open  air,  ii.  230 
Hilus,  infection,  i.  54,  110,  112 
diagnosis  of,  i.  114 
importance  of,  i.   596 
involved,  no  matter  how  bacilli  en- 
ter body,  i.   31 

Hilus,  normal  shadow  in  x-ray  plate, 

i.  521 
Hilus,  palpation  in  examination  of,  i. 

115 
Hinsdale,  discussion  of  climate,  ii.  255 
variability   of   oxygen    and   carbon 

dioxide  in  air,  ii.  263,  265 
History,    clinical,    eases    illustrating, 

ii.   534,   542,   553,   566,   579, 

590,  599,  609,  621,  631,  650, 
659 

of  tuberculosis,  ii.  524 
Hoarseness,  due  to  tuberculosis,  usu- 
ally   accompanied    by    other 
symptoms,  i.   603 
in  advanced  tuberculosis,  i.  447 
in   early   active   tuberculosis,   cases 
illustrating,  ii.  527,  554,  566, 

591,  600,  622,  625,  650 
in  tuberculous  laryngitis,  ii.  24 
method  of  its  production,  i.  385 

Holmes,  changes  in  neutrophile,  i.  577 

Holzknecht,   cause   of   trunk  shadows 

in  lung  plate,  i.  522 


Home  treatment,  ii.  470 
care  of  sputum  in,  ii.  478 
diet   must  be   prescribed   carefully 

in,  ii.  474 
how  arrange  home  for,  ii.  471 
how  often  see  patient  in,  ii.  480 
over    anxiety    of    friends    must    be 

avoided  in,  ii.  473 
problems  of,  ii.  470 
prognosis  in,  i.  645 
program  for,  ii.  476 
training  family  for,  ii.  472 
training  patient  for,  ii.  475 
Homogenization    of    sputum,    advan- 
tage of,  i.  552,  554 
Hope,  effect  of,  on  patient,  ii.  391 

essential  to  cooperation,  ii.  395 
Hopefulness  of  patient,  i.  155 
Hormone,    theory    and    digestion,    i. 

257 
Horseback  riding,  not  suitable,  ii.  299 
Hospital,    general,    is    tuberculosis    a 

danger  in,  ii.  518 
Hot  water  bottles,  use  of,  to  be  dis- 
couraged, ii.  250 
Huggard,    discussion    of    climate,    ii. 

254 
Humidity    of    atmosphere,    effect    on 

body,  ii.  243,  258 
Huntington,  discussion  of  climate,  ii. 

255 
Hydrotherapy,  ii.  401 

and  prognosis,  i.  649 
Hygiene,  personal,  of  patient,  ii.  512 
Hyperchlorhydria,      during      toxemia 
caused  by  reflex  stimulation 
of  vagus,  i.  260 
in  tuberculosis,  i.   260 
treatment  of,  i.  261 
Hyperesthesia    and    hyperalgesia,    of 

skin  in  tuberculosis,  i.  453 
Hypersensitiveness,     precipitated     by 
rapid  cleavage  of  protein,  ii. 
347 
to  tuberculin,  ii,  347 
Hypersthenic  type  of  individual,  char- 
acteristics of,  i.  339 
Hypochlorhydria,    in    tuberculosis,    i. 
259 
treatment  of,  i.  259 
Hypophosphates  in  treatment,  ii.  467 
Hyposthenie  type  of  individual,  char- 
acteristics of,  i.  348,  355 
Hypotension,  effects  of,  i.  306 


INDEX 


675 


Immunity,  and  infection,  i.  95 
child  gradually  develops,  i.  96 
greatest  in  children  of  tuberculous 

families,    i.    362 
high   degree  of,  in  tuberculosis,  i. 

96,  ii.  330 
in  tuberculosis,  relative,  i.   96;    ii. 

195 
produced  by  tuberculin,  ii.  330 
Immunization,  active,  experiments  on, 
i.  96 
artificial  attempts  at,  ii.  335 
Imperial  German  Board  of  Health's 
statistics  of  bovine  and  hu- 
man infection,  i.  58 
Improvement  may  occur   in  spite  of 

serious  symptoms,  ii.  619 
Impulse,    afferent    third    and    fourth 
cervical     segments    of    cord 
center  of,  from  lug,  i.  181 
"Incipient  tuberculosis, ' '  i.  357 

a  misnomer,   ii.    283 
Incubation  period   in  tuberculosis,  i. 

65 
Indican  and  overfeeding,  i.  587 
method  of  determining,  i.  572 
weather,  i.  587 
Infarct,      pulmonary,      differentiated 

from  tuberculosis,  i.  616 
Infection,  aerogenous,  i.  29,  6Q 
difficulties  of,  i.   67 
alimentary,   i.   69 
and  immunity,  i.  95 
avenues  of,  i.  29 
bovine,   ii.    514 

bronchial,    favored   by    cough    and 
deep   breathing,   i.   37,   452; 
ii.   306 
danger    of,    lessened    by    artificial 

pneumothorax,  ii.  433 
dangerous  until  healed,  ii.  195 
droplet,  i.  68;   ii.  513 
dust,   ii.    512 

early,      semiquiescent,      effect      on 
growth,  case  illustrating,  ii. 
603 
symptoms  not  recognized,  case  il- 
lustrating, ii.  570 
effect  of,  upon  child,  i.  108 
fate  of  early,  i.  107 
finger  nails,  source  of,  i.  73 
follows  course  of  soot,  i.  134 
frequency  of  in  adult  lung,  i.  406 
from  without  in  adult  life,  i.  89 


Infection — Cont  'd 

in  children  of  tuberculous  families, 

i.  362 
in  pneumothorax,  ii.  79 
intestinal  and  mesenteric  glands,  i. 

71 
in  tuberculous  families,  i.  103 
lessened  danger  of,  to  adults,  i.  92 
localization  of,  i.  31 

differs  in  child  and  adult,  i.  124 
differs   with    changes     in     bony 
thorax,  i.  130 
lymphatic   structures   protect   child 

against,  ii.   196 
metastatic,    early    clinical    tubercu- 
losis, ii.  189 
method  of,  ii.  21 
mixed,  not  common  in  tuberculosis, 

ii.  122 
not  spread  in  sanatoria,  ii.  519 
of  child,  ii.  503 
of  larynx,  cause  of,  ii.  20 
primary  and  metastatic  contrasted, 

i.    82 
primary  intestinal,  ii.  33 
pulmonary  localization  of,  depends 
on   anatomical   and   develop- 
mental   factors,    i.    123 
reflex    changes    in    superficial    soft 

tissues,  as  result  of,  i.  397 
relationship  to  clinical  diagnosis,  i. 

359 
relative     difficulties     of     infection 
from  without  and  within,  i. 
89 
size  of,  important,  i.  92 
source  of,   i.   57 

difficulty  of  determining,  i.  78 
through    skin,    i.    80 
through  skin,  i.   80 

uninjured   mucous    membrane,    i. 
30 
what  predisposes  child  to,  i.  99 
without  cellular  defense,  i.  34 
Infiltration,    pulmonary,    changes    on 
auscultation  in,  i.  488 
inspection  in,  i.  482 
palpation  in,  i.  484 
percussion   in,   i.    485 
diagnosis  of,  i.  482 
Infiltrations,    determined    by    palpa- 
tion, i.  413 
Inflammation,  collateral,  cause  of,  i. 
26 
exudative,  ii.   349 


676 


INDEX 


Inflammation,  collateral — Cont  'd 
injures  tissues,  i.  86 
nature  of,  i.   26 
undergoes  same  change  as  tuber- 
cle, i.  26 
tuberculosis,     characteristic    of,    i. 
27 
Influenza,    active    tuberculosis    often 
diagnosed  as,  ii.  659 
and  tuberculosis,  differentiation  of, 
i.  614 
Ingestion,  of  bacilli,  historical  sketch, 
i.  75 
of  inhaled  bacillli,  i.  72 
Inhibition  in  visceral  nerves,  i.  174 
Inland  climates,  ii.  268 

Innervation  of  muscles  of  forced  res- 
piration, i.  327 

Insanity  and  tuberculosis,  i.    150 
Insomnia,  cause  of,  ii.  458 

treatment  of,  ii.  459 
Inspection,  a  most  important  but  neg- 
lected method  of  diagnosis,  i. 
402 
cases    illustrating    careful,    in    ad- 
vanced tuberculosis,  i.  469 
condition  of  subcutaneous  tissue  de- 
termined by,  i.  405,  466 
in  advanced  tuberculosis,  i.  464 
in  compensatory  emphysema,  i.  494 
in   diagnosis,  i.  402,   464 

cases  illustrating,    ii.    526,    535, 
543,  555,  567,  601,  611,  622, 
633,  652 
in  dry  pleurisy,  i.  496 
in  mediastinal    tumors,    i.    500 
in  pleural  effusion,  i.  496 
in  pulmonary  cavity,  i.  490 

infiltration,  i.  482 
in  thickened  pleura,  i.  497 
lagging  detected  by,  i.  404,  468 
may  show  evidence  of  active  pulmo- 
nary lesion,  i.  402,  468 
muscle  spasm  and  degeneration  de- 
termined by,  i.  405,  466 
of  great  value  in  diagnosis,  i.  397, 

402,  464 
probable  diagnosis  made  by,  i.  464 
rules  for,  i.  464 
Inspiratory  act,  i.  295 

increases    circulatory     efficiency,    i. 

301;  ii.  289 
results  of  lessening,  i.  303 
symptoms  of  deficiency  in,  i.  303 


Intercostal    muscles,    changes   in,    in 
pleural  adhesions,  ii.  59 
pathological  changes  in,  in  pleuri- 
sy, ii.  61 
Intercostal  neuralgia,  and  early  clin- 
ical tuberculosis,  i.  364 
and  tuberculosis,  differentiation  of, 
i.  613 
Intercostal    spaces,    bulging    of,    in 

pneumothorax,  ii.  80 
Intercostals,  innervation  of,  i.  325 
Internal  secretion  of  ovary,  i.  195 

suprarenal  gland,  i.   173,  219,  605 
Internal    secretions,    influence   symp- 
toms, i.  194,  228 
relation  to  toxic  state,  i.  366 
Internal  viscera,  degenerative  changes 
in,  possibly  due  to  reflex  irri- 
tation, i.  606 
Intertransmissibility    of    bovine    and 

human  bacilli,  i.  57 
Intestinal  canal,  innervation  of,  i.  176 
mucous  membrane  of  child,  easily 

penetrated,  i.  71,  100 
route  of  infection,  i.  53 
stasis  in  tuberculosis,  i.  266 
tract,  motility  of,  in  anaphylaxis, 
ii.  160 
Intestine,  disturbance  of,  in  tubercu- 
losis,  i.   215,   264 
lungs  embryologically  formed  from, 

i.  181;  ii.   165 
performation  of,  in  tuberculous  en- 
teritis,   case   illustrating,    ii. 
661 
primary  infection  of,  i.  52 
sympathetic  and  greater  vagus  ac- 
tion on,  i.   211,  215 
thickening    of    wall    of,    in   tuber- 
culous  infection,    case   illus- 
trating, ii.  656 
tuberculosis  of,   {see  Enteritis,  tu- 
berculous) 
tuberculosis  of,  in  prognosis,  i.  632 
Intrathoracic     pressure    negative,     i. 

302 
Iodine  in  treatment,  ii.  465 
Iron  in  treatment  of  tuberculosis,  ii. 

468 
Itching    of    skin    in    anaphylaxis,    ii. 
160 


Jacob,  study  of  infection  of  country 
children,  i.  79 


INDEX 


677 


Jobling  and  Peterson,  action  of  io- 
dine, ii.  465 

Joint  and  bone  infection,  percentage 
of,  bovine  and  human,  i.  58 

Joints,  tuberculosis  of,  ii.   106 

Jona,  heat  production  and  loss  during 
experimental  fever,  ii.  112 

Joseph,  incubation  period  in  tubercu- 
losis, i.  65 

K 

Katathermometer,  description  and  in- 
struction for  use  of,  ii.  238 
Keith,  believes  lessened  expansion  fa- 
vors implantation,  i.  147 
human  embryology  and  morphology, 
i.  169 
Kellogg  discusses   variety   of   nerves 

supplying  skin,  ii.  401 
Kernig's  sign  in  tuberculous  menin- 
gitis, ii.  90 
Kidd,  statistics  of  aneurism  and  fatal 

hemorrhage,  ii.  172 
Kidney,  tuberculosis  of,  ii.  96 
tuberculous,     catheterization     may 
give  no  evidence  in,  ii.  98 
clinical  healing  of,  ii.  100 
healing  of,  ii.  97 
operation  for,  ii.  97 
pain  in,  ii.  98 

routes  of  infection  in,  ii.  96 
spasm  of  lumbar  muscles  in,  ii. 

98 
symptoms  of,  ii.  97 
treatment  of,  ii.  100 
tuberculin  treatment  of,  ii.  100 
urine  in,  ii.   98 
Kidneys,  both  may  be  infected,  yet 

not  show  in  urine,  ii.  97 
Kime,  reflector  for  sun  treatment,  ii. 

427 
Kinetic  system    (Crile),  i.   219 
Kinyoun's  method  of  using  mechan- 
ical shaker,  i.  555 
Klebs,   what    sanatorium   stands   for, 

ii.  484 
Knopf,     advantages     of     sanatorium 

treatment,  ii.  482 
Koch,  and  intertransmissibility  of  bo- 
vine and  human  bacilli,  i.  57 
and  tuberculin  reaction,  ii.  336 
artificial  immunization,  ii.  335 
Koch's,  experiment  showing  cell  sen- 
sitization, i.  82 
idea  of  primary  intestinal  infection, 
i.  52;  ii.  33 


Konig,  favors  operation  for  tubercu- 
lous peritonitis,  i.  50 

Krause,    and    tuberculin   reaction,   ii. 
336 
tuberculin     hypersensitiveness    and 
character  of  lesion,  i.  505 

Krumwiede,  shows  relative  percentage 
of  bovine  and  human  infec- 
tion, i.  58 


Laboratory,  findings,   aid  in  diagno- 
sis and  in  understanding  of 
complications,  i.  481 
correlation  of,  i.  589 

case  illustrating,  i.  593 
interpretation  of,  i.  581 
of  limited  prognostic  value,  i.  501 
methods,  i.  533 
Lagging,  cause  of,  i.  403 

decreased    elasticity    of    pulmonary 

tissue,  as  cause  of,  i.  403 
detected   by  inspection,   i.   403 

palpation,  i.  416 
due    to    diaphragm    reflex    through 

phrenics,  i.  403,  468 
of  both  sides  difficult  to  detect,  i. 

404,  416 
overcome  by  deep  breathing,  i.  404 
regional  and  general,  how  detected, 

i.  403 
value  of,  as  diagnostic  sign,  i.  403 
La   grippe   and   early   clinical  tuber- 
culosis, i.  364 
Lampson,   statistics   of   infections  in 
tuberculous   families,   i.   103 
Landis,  pulmonary  syphilis,  i.  619 
Laryngitis,  tuberculous,  ii.  17 
case  of,  ii.  20 
cough  in,  ii.  26 
diagnosis  of,  ii.  24 
differentiated  from  syphilis   and 

cancer,  ii.  27 
frequency  of,  ii.  18 
hoarseness  in,  ii.   24 
laryngologist  's  and  chest  special- 
ist's  opinions   of,  differ,  ii. 
31 
lymph   glands  not  commonly  in- 
volved in,  i.  83 
obstructed  respiration  in,  ii.  26 
pain  in,  ii.   25 

painful  deglutition  in,  ii.  26 
pale  mucous  membrane  in,  ii.  28 
pathology  of,  i.  47 


678 


INDEX 


Laryngitis,  tuberculous — Cont'd 

percentage  in  male  and  female, 

ii.  19 
prognosis  in,  ii.  23 
secretion  in,  ii.  26 
treatment  of,  ii.  28 
tuberculin  in  diagnosis  of,  ii.  28 
Larynx,  and  bifurcation    of    trachea, 
points  of  increased  sensibil- 
ity, i.  451 
incidence  of  infection  of,  depends 
on    pulmonary   condition,   ii. 
19 
irritation  in,  as  early  symptom,  i. 
386 
directs      attention     away     from 
lungs,  i.  387 
location  of  infection  in,  i.  47 
method  of  infection  of,  i.   90;   ii. 

21 
neuritis   of,  i.  450 
percentage  of  infection  in,  i.  48 
should    be    routinely    examined,    ii. 

18,  26 
surface  infection  of,  i.  47 
throat  compress  in  treatment  of,  ii. 

411 
tuberculin  reaction  in,  ii.   18 
tuberculosis  of,  case  illustrating,  ii. 
592,  626,  630 
in  prognosis,  i.  631 
secondary,  i.  47 
treated  by  tuberculin,  ii.  384 
tuberculous  process  in,  easily  stud- 
ied, ii.  17 
Latent  tuberculosis,  dangerous  to  pa- 
tient, i.  110 
importance  of  recognizing  in  early 
life,  i.  110 
Latham,    advantages    of    sanatorium 

treatment,  ii.  482 
Lee,  studies  on  open  air,  ii.  230 
Lesions,  apical,  activity  in,  determined 
by  inspection  and  palpation, 
i.  407 
Leucopenia  and  miliary  tuberculosis, 

i.  591 
Levastine,  degeneration  of  brain  cells, 

i.  160 
Levator    anguli    scapulae,    innervation 
of,  i.  331 
spasm  and  degeneration  of,  in  diag- 
nosis, i.  401 
Lewandowsky,    function    of    central 
nervous  system,  i.  169 


Light,    application   of,   in  treatment, 
ii.  421 
augments  oxidation,  ii.  420 
blondes    versus    brunettes,    as    af- 
fected by,  ii.  426 
dosage  important,  ii.  427 
effect  of,  on  bacteria,  ii.  418 
on  blood,  ii.  420 
on  human  being,  ii.  420 
on  skin,  ii.  418 
energy  of,  consists  of  vibrations,  ii. 

215 
fundamental  principles  of,  ii.  414 
penetration  of  tissues  by,  ii.  419 
physiological  effects  of,  ii.  418 
sun,  concentrated  as  a  bath,  ii.  427 
ultraviolet,      percentage      reaching 
earth,  ii.  417 
suffers  loss  in  atmosphere,  ii.  417 
vibration  rate  of  various  colors  of, 
ii.  415 
Ligroin  in  examination  of  sputum,  i. 

555 
Liver,  tuberculosis  of,  i.  53 
Lobes,  position  of  divisions  between, 

i.  321 
Lord,  on  cause  of  pleural  effusion,  ii. 

84 
Lung,  antagonistic  action  of  sympa- 
thetic and  greater  vagus  in 
the  production  of  symptoms 
when  inflamed,  i.  198 
early  metastases  in,  fibroid  in  char- 
acter, i.  36;  ii.  189 
effect  of  compression  of,  ii.  430 
embryologically  formed  from  intes- 
tine, i.  181;  ii.  165 
exercise  for,  ii.  204 
growth  of,  at  different  age  periods, 

i.  127 
infected  by  bacilli  injected  into  rec- 
tum, i.  30,  71 
infection  of,  from  within  and  with- 
out, difference  in,  i.  89 
through  intestine,  i.   72 
inflammation      of,     causes     reflex 
changes  in  chest  muscles  and 
subcutaneous      tissues      over 
them,  i.  408 
injury  during  artificial  pneumotho- 
rax, ii.  441 
malignant  tumors  of,  i.  621 
marked    compensatory    changes    in, 

shown  at  autopsy,  ii.  594 
motor  reflex  from,  i.  454 


INDEX 


679 


Lung— Cont  'd 

necrosis  and  caseation  of,  case  illus- 
trating, ii.  613 
nerve  supply  of,  i.  179 
primary   foci  in,   may   result  from 

intestinal  infection,  ii.  34 
projection  of,  on  anterior  surface  of 

chest  wall,  i.  319 
receives    innervation    from    sympa- 
thetic and  vagus,  i.  180,  192, 
198 
reserve  area  of,  i.  285 
rest  for,  ii.  304 

sensory  area  of  skin  from,  i.  454 
sympathetic  nerve  supply  of,  i.    180 
why  so  often  infected,  i.  32 
Lung  focus,  relationship  to  glands,  i. 

30,  83,  89 
Lungs,   motor   segmental   relationship 
to  body  surface,  i.  179 
normal  borders  of,  i.  320 
segmental  relationship  of,  i.  179 
sensory  segmental   relationship   of, 
to  body  surface,  i.  179 
Lymph,  and  blood  flow  influenced  by 

stimulation  of  skin,  ii.  402 
Lymph  flow,  favored  by  respiration, 

i.  37 
Lymph  spaces,  widened  by  inspiration, 

favor  infection,  i.  36 
Lymph  stream,  bacilli  may  be  carried 

against,  i.  37,  62 
Lymphatic  infection,  favored  by,  i.  37 
in  child  and  clinical  tubercuolsis  in 
adult,  i.  70,  110 
Lymphatic    system,    tuberculosis    pri- 
marily a  disease  of,  i.  32,  48, 
55 
Lymphatic  tissue,   importance    of   in 

childhood,  i.  93 
Lymphatic  tuberculosis,  in  early  life, 

importance  of,  i.  110,  112 
Lymphatics,  part  in  disseminating  in- 
fection, i.  55 
role   of,  in  protection  of   child,  ii. 

505 
subpleural,  absorptive  power  of,  i. 
49 
Lymphocyte  count,  high,  questionable 

diagnostic  value  of,  i.  585 
Lymphocytes  in  sputum,  i.  536 
diagnostic  value  of,  i.  582 


M 

Mackenzie  emphasizes  sensory  disturb- 
ance of  skin,  i.  454 

Malaise,  in  tuberculosis,  i.  369,  438 
part    of    syndrome    of    toxemia,    i. 
223,   226;    ii.   110 

Malaria  and  early  clinical  tuberculo- 
sis, i.   364,  612 

Malignant  tumors  of  lung,  i.  621 

Mammary  gland,  degeneration  of, 
sign  of  reflex  trophic  change 
from  inflammation  in  lung,  i. 
409 

Manteaux,  intradermal  tuberculin  test, 
i.   502,  515 

Maragliano  and  artificial  immuniza- 
tion, ii.  335 

Marriage   and   tuberculosis,  ii.  516 

Mattison,  resection  of  cecum  and  as- 
cending colon,  case  illustrat- 
ing, ii.  654 

Maxwell  shows  colloidal  solution  re- 
tards gastric  digestion,  i.  256 

McCarthy  and  Carncross,  statistics  of 
mental  attitude  of  the  tuber- 
culous, i.  153 

McCarthy,  describes  tuberculous  ul- 
ceration of  brain  substance, 
ii.  89 

McGowan,  on  conservative  treatment 
of  genitourinary  tuberculo- 
sis, ii.    100 

Mechanical  shaker,  in  examination  of 
sputum,  i.  554 

Mediastinal  thickening,  in  advanced 
tuberculosis,  i.  499 

Mediastinum,     displacement     of,     in 
pneumothorax,  ii.  79 
part    in    compensatory    changes,    i. 

.     282 
shifting  of,  i.  285,  293 

Medical  guidance,  tuberculous  patient 
requires  close,  ii.  223 

Medical    profession,    ability    of,    to 
cope    with    tuberculosis,    im- 
proving, ii.  209 
prevailing    attitude    of,  toward  tu- 
berculosis, ii.  208,  210 

Mehnert,  shows  inclination  of  ribs  at 
different  age  periods,  i.  128 

Meningitis,  tuberculous,  ii.   88 
cause  of,  ii.  88 
diagnosis  of,  ii.  90 
exudate  in,  ii.  88 
eye  symptoms  in,  ii.  90 


680 


INDEX 


Meningitis,  tuberculous — Cont  'd 
fever  in,  ii.  89 

gastrointestinal  tract  in,  ii.  90 
headache  in,  ii.  89 
healing  may  follow,  ii.  88,  91 
in  prognosis,  i.  633 
Kernig  's  sign  in,  ii.  90 
muscle  rigidity  in,  ii.   90 
nervous  system  in,  ii.  89 
pulse  in,  ii.  89 
symptomatology,  ii.  89 
treatment  of,  ii.  90 
Menopause,  and  ovarian  secretion,  i. 
195 
premature  in  advanced  tuberculosis, 
i.  462 
Menstrual  period,  less  resistance  dur- 
ing, i.  462 
nervous  symptoms  during,  i.  462 
Menstrual  rise,  in  temperature,  i.  380 ; 

ii.  149 
Menstrual  wave,  cause  of,  i.  195 
Menstruation,  and  ovarian  secretion, 
i.    195 
in  advance  tuberculosis,  i.  461 
vicarious,  i.  391 
Mental    attitude,    in    tuberculosis,    i. 

153,  156 
Mental  processes,  disturbed  in  tuber- 
culosis, ii.  393 
Mental  state,  in  prognosis,  i.  628 
Menthol,  in  treatment  of  tuberculous 
enteritis,  case  illustrating,  ii. 
648 
Metabolism,  changes  with  weather  in- 
fluences, ii.  275 
improved  by  open  air,  ii.  244,  248 
increased  by  exercise,  ii.  277 
stimulated  by,  cold,  ii.  272 

sunlight  and  air  currents,  ii.  270 
Metallic    tinkling,    in    pneumothorax, 

ii.  81 
Metastases,  follow  activity  in  existing 
focus,    case    illustrating,    ii. 
626 
hematogenous,  i.  31,  38 
in  lung,  early,  fibroid  in  character, 

i.  35,  85;   ii.  189 
lymphatic,  i.  36 

primary,  and  primary  focus,  i.  82 
relation   to    clinical   tuberculosis, 
i.  85 
production  of,  hindered  by  cellular 

defense,  i.  35;  ii.  198 
pulmonary,  factors  favoring,  i.  120 
secondary,  i.  35 


Metastatic  tuberculosis,  i.  118,  359 
Miliary  tuberculosis,  acute,  tempera- 
ture curve  of,  ii.  128 
and  leucopenia,  i.  591 
cause  of,  i.  40,  241 
in  prognosis,  i.  628 
Miller,  establishes  open  air  school  for 
tuberculous  children,  ii.  268 
Mills,  the  relation  of  visceral  form, 
topography  and  function  to 
the    general    physique,    with 
classification  of  types,  i.  335 
Minor,  value  of  x-ray  in  diagnosis,  i. 

518 
Mixed    infection,    argument    against, 
from  pneumothorax,  ii.  83 
not  common  in  tuberculosis,  ii.  122 
Moro,  percutaneous  tuberculin  test,  i. 

502,  515 
Morphine,    in    treatment    of    hemor- 
rhage, ii.   176 
Mortality  by  age  periods,  i.  97 
Motility,   changes   in,  in  tuberculous 

enteritis,  ii.  40 
Motor  reflex,  from  diaphragm,  i.  403 
from  intestines,  ii.  43 
from  kidney,  ii.  98 
from  lungs,  paths  of,  i.  179 
Much,  and  artificial  immunization,  ii. 

335 
Much's  granules,  stain  for,  i.  559 
Mucous  membranes,  adaptation  of  to 

climatic  change,  ii.  258 
Municipality,  duty  of,  in  preventing 

tuberculosis,  ii.  514 
Murphy,    artificial   pneumothorax,    ii. 

429 
Muscle,     normal,     description    of,     i. 

406,  411 
Muscle  changes,  interpretation  of,  i. 

405,  407 
Muscle  degeneration,  cause  of,  i.  399 
condition  described,  i.  412,  474 
description  of,  as  sign  of  chronic 
pulmonary    inflammation,    i. 
412 
in  advanced  tuberculosis,  i.  466 
regional,  denotes  chronicity,  i.  412, 
466,  473 
Muscle  reflex,  disappears  when  inflam- 
mation heals,  i.  411 
importance  of,  in  diagnosis,  i.  610 
in  tuberculous  enteritis,  ii.  43 
method  of  determining,  i.  411 


INDEX 


681 


Muscle  rigidity,  symptom  of  tubercu- 
losis enteritis,  case  illustrat- 
ing, ii.  660 
Muscle  spasm,  cause  of,  i.  399 
description  of,  i.  406,  411 
in  advanced  tuberculosis,  i.  466 
regional,    denotes    activity,    i.    399, 
412,  466,  473 
Muscles,  and  other  soft  tissues,  effect 
of  on  palpation,  percussion, 
and    auscultation    shown    by 
thickness  of,  i.  332 
and   subcutaneous   tissue,   influence 
on  percussion,  i.  422 
over  thickened  pleura,  i.  498 
condition  of,  alters,  auscultation,  i. 
398 
palpation,  i.  398 
percussion,  i.  398 
in  active  tuberculosis,  i.  399;  ii. 

525 
in  moderately  advanced  tubercu- 
losis, ii.  535 
degeneration  of,  from  use,  i.  475 
lowers   percussion    note    and    de- 
creases resistance,  i.  477 
effect  of,  occupation  upon,  i.   333, 
405,  413 
on  respiratory  note,  i.  428,  479 
increased  tone  in,  raises  percussion 
note  and  increases  resistance, 
i.  477 
in  diagnosis,  cases  illustrating,  li. 
525,  535,  543,  554,  567,  580, 
610,  622,  633 
influence  of,  on  physical  findings,  i. 

332 
involved  in  reflex  from  lung,  i.  179, 
408 
respiration,  i.  296,  326 
lumbar,   spasm   of,  in   tuberculosis 

of  kidney,  ii.  98 
part  of,  in  deformity  of  bony  tho- 
rax, i.  294 
pathological  changes  in,  i.  44,  399, 
405 
vs.  occupational  changes  in,  i.  405 
power  of,  reduced  in  chronic  tuber- 
culosis, ii.  393 
reflex  spasm  of,  cause  of,  i.  399 
in  advanced  tuberculosis  difficult 
to  detect,  i.  467 
reflex  trophic  changes  in,  i.  400,  466 
regional  spasm  and  degeneration  of, 
in    diagnosis    of    pulmonary 
tuberculosis,  i.  410,  466 


Muscles — Cont  'd 

rigidity  of,  in   tuberculous  menin- 
gitis, ii.  90 
somatic,  segmental  innervation  of, 

i.  179,  329 
spasm  of,  shows  healing  not  com- 
plete, ii.  539 
superficial,    spasm    of,    i.  179,  399, 
405,  604 
Muscular  action,  effect  of,  on  circula- 
tion, ii.  402 
Muscular     element,     in     respiratory 
sound,    i.    431 

N 

Naegeli,  statistics  of  pulmonary  infec- 
tion in  adults,  i.  Ill,  408; 
ii.  191 
Nausea,  in  anaphylaxis,  ii.  159 
in  dilatation  of  stomach,  i.  263 
in  tuberculosis,  i.  215,  439 
in- tuberculous  enteritis,  i.  444;  ii. 
39 
Necrosis,  not  due  to  pus  organisms, 
i.  48 
of  vessel  causes  hemorrhage,  ii.  172 
Nerve,  recurrent  laryngeal,  in  causing 
hoarseness,  i.  386 
superior     laryngeal,      in     causing 
hoarseness,  i.  386 
Nerve  action,  selectivity  of,  i.  220 
Nerve  cells,  act  only  if  impulse  is  suf- 
ficient, i.  220 
affected  differently  by  helpful  and 

harmful  stimuli,  ii.  394 
changes    in,    following    depressive 

emotions,  i.  43 
fatigue  of,  must  be  appreciated  in 

treatment,  ii.  528 
injured  by  long  continued  harmful 
stimuli  such  as  toxins,  i.  220, 
221 
irritability  of,  in  neurasthenia,  ii. 
398 
Nerve  control,  of  blood  vessels,  i.  232 
of  gastrointestinal   tract,   i.    278 
of  heart,  i.  230 
of  visceral  activity,  ii.  392 
Nerve  equilibrium,  disturbed  by  tox- 
ins, ii.  390 
Nerve  exhaustion,   calls   for  rest,   ii. 

294 
Nerves,  pathological  changes  in,  i.  44 
Nervous    influences,    shown    on   pulse 
and  temperature,  ii.  531 


682 


INDEX 


Nervous  influences — Cont'd 

upon  temperature  curve,  ii.  146 
Nervous  instability,  part  of  syndrome 

of  toxemia,  ii.  110 
Nervous  system,  and  nutrition,  ii.  328 
and  prognosis,  i.  636 
and  toxemia,  i.  151,  158,  189,  217, 

366,  612;  ii.  527 
central,  connection  of,  with  vegeta- 
tive system,  i.  170 
controls  heat  loss,  ii.  115 
Night  or  sleep  sweats,  i.  445;  ii.  449 
cold  sponge  in,  ii.  451 
effect  of  open  air  on,  ii.  451 
part    of    syndrome    of    toxemia,    i. 

371;  ii.  110 
treatment  of,  ii.  451 
vinegar  bath  in,  ii.  451 

Nitrites,  in  treatment  of  hemorrhage, 

ii.  178 
Non-tuberculous  changes,  i.  42 
Nose,  tuberculosis  of,  i.  46 
Nutrition,  affected  by  abnormal,  cir- 
culation, ii.  328 
respiratory  action,  ii.  328 
nervous  system,  ii.  328 
as  long  as  patient  maintains,  out- 
come hopeful,  ii.  550 
changes   in,   in   tuberculous   enteri- 
tis, ii.  39 
conception  of,  i.  251 
degree  of,  modifies  visceral  form,  i. 

336 
in  tuberculosis,  i.  252 
low,  calls  for  rest,  ii.  293 
maintained  on  variable  diets,  ii.  308 
relation  of  body  cells  to,  ii.  327 
Nervous  system,  degenerative  diseases 
of,    common    in    tuberculous 
families,  i.  150 
greater  vagus,  i.  170 
importance   of  understanding  rela- 
tionship   to    tuberculosis,    i. 
150,  168,  217,  604 
in  tuberculous  meningitis,  ii.  89 

i.  150,  168,  217 
sympathetic,  i.  170 
vegetative,  i.  169 

and  anaphylaxis,  ii.  157 
pathological  degeneration  in  in- 
ternal viscera,  a  result  of  ir- 
ritation of,  i.  606 
reflex  disturbance  of  function  of 
internal  viscera,  due  to,  i. 
199-216,  254 


Nervus  pelvicus,  part  of  greater  vagus 

system,  i.  186 
Neumann,  on  congestive  type  of  hem- 
orrhage, ii.  175,  180 
Neurasthenia,  ii.  294,  390 

and    early    clinical    tuberculosis,    i. 

364 
and  rest,  ii.  294 
and  tuberculosis,  i.  158,  612 
improved  by  open  air,  ii.  248 
method  of  explaining  to  patient,  ii. 

528 
necessity  of  hope  in,  i.  530 
treatment    of,    in    tuberculosis,    ii. 
398 
Neuritis,  and  tuberculosis,  i.  161;  ii. 
456 
brachial  and  tuberculosis,  i.  161 
in  tuberculosis,  pathology  of,  i.  167 
of  laryngeal  nerves,  i.  450 
Neutrophiles,    Arneth  's    classification 
of,  i.  577 
from  pulmonary  cavities  stain  poor- 
ly, i.  536 
nuclear    and   protoplasmic    changes 
in,  i.  577 
Newsholm,  statistics  of  mortality  by 
age  periods,  i.  98 


O 


Occupation,  change  of,  and  prognosis, 

i.  655 
Occupational    changes   in   chest   mus- 
cles, i.  333,  405,  413 
Ocean  voyages,  objections  to,  ii.  266 
Old   tuberculin    (O.    T.)     (Koch),  ii. 

354 
Open  air,  ii.  227 

a   great   advance   in   treatment,  ii. 

228 
and  fog,  ii.  252 
and  prognosis,  i.  646 
and  weather  conditions,  ii.  252 
causes  greater  demand  for  food,  ii. 

248 
effects  of,  ii.  248 

on  non-tuberculous  same  as  on  tu- 
berculous, ii.  229 
food  and  hygiene  not  cures  for  tu- 
berculosis, ii.  203,  227,  252 
improves  metabolism,  ii.  244,  248 
increases,    patient's    resistance,    ii. 
246 
pulmonary  ventilation,  ii.  239 


INDEX 


683 


Open  air — Cont'd 

individualization   in   dosage   of,   ii. 

247 
judgment  necessary  in  exposing  pa- 
tients to,  ii.  247 
on  what  does  benefit  depend,  ii.  229 
opposed  by  many,  ii.  228 
oxygen  not  most  important  factor 

in,  ii.  229 
patient's  resisting  power  should  be 
considered  in  instituting,  ii. 
249 
should  be  assisted  by  other  meas- 
ures, ii.  227 
wrongly  conveys  idea  of  exercise,  ii. 
252 
Open    air    treatment,    technic    of,    ii. 

248 
Open  tuberculosis,  in  family,  meaning 

of,  in  history,  i.  362 
Organs,  displacement  of,  in  tubercu- 
losis, i.  253 
Orth,  manner  in  which  trauma  acti- 
vates tuberculosis,  i.  314 
Ovary,  internal  secretion  of,  i.  195 
secretion  of,  effect  on  temperature, 

case  illustrating,  ii.  639 
tuberculosis  of,  ii.  103 
tuberculous,   healed   by   tuberculin, 
ii.  103 
Overexertion  and  hemorrhage,  ii.  168 
Overfeeding,  and  indican,  i.  587 
evil  effects  of,  ii.  310,  313 
no  excuse  for,  in  early  tuberculosis, 

ii.  312 
sometimes  permissible,  ii.  313 
Oxygen,  amount  necessary  for  body 
during  rest  and  exercise,  ii. 
279 
deficency    of,    causes    acidosis,    ii, 

281,  292 
not  most  important  factor  in  open 
air,  ii.  229 
Oxygenation,  factors  interfering  with, 

case  illustrating,  ii.  584 
Ozone,  effect  on  tuberculosis,  ii.  262 


Pain,  codein  and  Dover's  powder  in, 
ii.  457 
due  to  neuritis  in  tuberculosis,  ii. 
456 
stretching  adhesions,  i.  453 
heart  in  treatment  of,  ii.  457 
in  pneumothorax,  ii.  75 


Pain— Cont  'd 

in  shoulders,  i,  388,  452 

reflex  as  sign  of  inflammation  in 
lung,    cases    illustrating,    ii. 
580,  608 
in  tuberculosis  of  kidney,  ii.  98 
in  tuberculous  enteritis,  ii.  40 

laryngitis,  ii.  25 
location  of,  in  acute  pleurisy,  ii.  56 

in  advanced  tuberculosis,  i.  452 
over  chest  areas  due  to  inflamma- 
tion of  abdominal  organs,  i. 
455 
treatment  of,  ii.  457 

in  tuberculous  enteritis,  case  il- 
lustrating, ii.  648 
when  cavity  forming,  i.  453 
zones  of,  in  tuberculosis,  ii.  456 
Pains,  chest  and  shoulder,  in  tuber- 
culosis, i.  388,  452 
due    to    reflex    trophic    changes    in 
nerves,  and  sensory  disturb- 
-     ances,  i.  452,  455 
Palpation,  and  percussion,  same  pro- 
cedure, i.  414 
deep,  cases  illustrating,  ii.  525,  535, 
543,  555,  567,  580,  610,  622, 
633,  651 
detecting  enlarged  Ivmphatic  glands 
by,  i.  410,  417 
infiltrations,    cavity,    emphysema, 
thickened    pleura,    effusions, 
mediastinal    thickening    and 
outline  of  organs  by,  i.  410 
tactile  fremitus  by,  i.  410,  417 
determining,  activity  of  pulmonary 
process  by,  i.  472 
compensatory   emphysema   by,   i. 

472 
condition    of    muscles,    skin    and 
subcutaneous    tissues    by,   i. 
410,  472,  473 
density  of  tissues,  i.  473,  476 
movement  of  chest  wall,  i.  468, 

472 
nature  of  infiltration,  i.  413,  472, 

484 
pathological   process   in   lung,   i. 

472 
pleural  adhesions,  i.  472 
presence  of  pleurisy,  i.  472,  496 

cavity,  i.  472,  490 
shifting  of  diaphragm,  i.  472 
mediastinum,  i.  472 
factors  causing  change  in,  i.  397 


684 


INDEX 


Palpation — Cont  'd 

importance  of  soft  tissues  in, 
shown  by  thickness  of,  i.  332 

in  advanced  tuberculosis,  i.  472 

in  compensatory  emphysema,  i.  495 

in  mediastinal  glands,  i.  115,  500 

in  pneumothorax,  ii.  79 

in  thickened  pleura,  i.  497 

lagging  detected  by,  i.  403,  410, 
416 

light  touch,  value  of,  i.  411 

of  deep  tissues,  suggestion  for  be- 
ginners, i.  424 

of  great  value  in  diagnosis,  i.  416, 
472 

what  can  be  determined  by,  in  pul- 
monary lesions,  i.  409 
Park,    shows    relative    percentage    of 
bovine  and  human  infection, 
i.  58 
Partial  antigens,  Koch's  O.   T.  con- 
tains greatest  number  of,  i. 
506 
Past   illness,   importance   of   in   clin- 
ical history,  i.  364 
Paterson,  graduated  exercise,  ii.  301 
Pathological    changes,    character    of, 

i.  25 
Patient,  co-operation  of,  depends  on 
attitude  of  physician,  ii.  212 
essential  to  cure,  i.  642 ;  ii.  211 
ease  illustrating,  ii.   538 

difficulty  of,  obtaining  diagnosis, 
case  illustrating,  ii.  558,  582 

effect  of  hope  on,  ii.  391 

feeding  of,  ii.  492 

haphazard  treatment  of,  proves  dis- 
astrous, case  illustrating,  ii. 
636 

helped  to  cure  self  by  psycho- 
therapy, ii.   389 

hope  required  by,  for  co-operation, 
ii.  395 

how  inform,  of  presence  of  tuber- 
culosis, ii.  397 

how  often  shall  physician  see,  ii. 
480 

if  ignorant,  fails  to  cooperate,  ii. 
219 

importance  of  resisting  power  in,  ii. 
508 

improves  in  spite  of  extensive  and 
active  disease,  case  illustrat- 
ing, ii.  575 

indifference  and  laziness  of,  ii.  301 


Patient — Cont  'd 

must  be  candid  with  physician,  ii. 
210 
cooperate  with  physician,  ii.  217 
follow  program,  ii.  476 

neglected  while  disease  is  empha- 
sized, ii.   388 

nervous,  unwise  to  find  fault  with, 
ii.  399 

personal  hygiene  of,  ii.  512 

reactive  powers  of,  to  bath,  vary 
with  conditions,  ii.  406 

relationship  of,  to  physician,  ii. 
208 

relieved  by  knowing  diagnosis,  ii. 
215 

sanitary  arrangement  of  room  for, 
ii.  510 

should  know  he  has  tuberculosis,  ii. 
213 

training  of,  important,  ii.  475 

tuberculous,  requires  close  medical 
guidance,  ii.  223 
Patients,  choice  of,  for  sanatorium,  ii. 
495 

importance  of  lecturing  to,  ii.  221 
Patton,    Noel,    internal    secretions,   i. 

69 
Pearson   and   artificial  immunization, 

■       ii.  335 
Pectoralis,  innervation  of,  i.  296,  328, 

331 
Percussion,  all  muscles  relaxed  during, 
i.  419 

common  errors  in,  i.  419 

condition  of  muscles  and  subcutan- 
eous tissue  alters  data  found 
on,  i.  477 

factors  causing  changes  in,  i.  397 

gives  no  evidence  of  activity,  i. 
426 

importance  of  soft  tissues  in,  shown 
by  thicknes  of,  i.  332 

important  muscles  which  affect,  i. 
419 

in  advanced  tuberculosis,  i.  477 

in  compensatory  emphysema,  i.  495 

in  diagnosis,  i.  417 

in  dry  pleurisy,  i.  496 

in  early  active  tuberculosis,  case  il- 
lustrating, ii.  526 

in  extensive  fibro-ulcerative  tuber- 
culosis, cases  illustrating,  ii. 
544,  555,  568,  581,  610,  622, 
634,  652 

in  mediastinal  thickening,  i.  500 


INDEX 


685 


Percussion — Cont  'd 
in  moderately  advanced  active  tu- 
berculosis,   case    illustrating, 
ii.  535 
in  pleural  effusion,  i.  496 
in  pneumothorax,  ii.  79 
in  pulmonary  cavity,  i.  490 
fibrosis,  i.  489 
infiltration,  i.  485 
light  or  heavy,  i.  417 
light   stroke  felt   through   chest,  i. 
418 
Percussion  changes,  in  chronic  focus 
again  active  in  one  lung,  and 
new  active  focus  in  other,  i. 
424 
in  early  pulmonary  tuberculosis,  i. 

420 
in  healed   focus   in  one  apex,   and 
active  focus  in  other,  i.  423 
in  primary    active    lesion    in    one 

apex,  i.  421 
in  quiescent  or  healed  lesion  in  one 
apex,  i.  421 
Percussion  findings,  in  old  focus  with 
renewed  activity  in  one  apex, 
i.  423 
Percussion  note,  altered  by  conditions 

within  chest,  i.  425 
Pericarditis,  complicating  pulmonary 
tuberculosis,    case    illustrat- 
ing, ii.  602 
tuberculous,  pathology  of,  i.  49 
Percardium,  displacement  of  heart  de- 
pends on  size  of,  i.  286 
case  illustrating,  ii.  598 
Peripheral  nerves  and  tuberculosis,  i. 

160,  167 
Peristalsis,  effect   of  emotions  on,  i. 

279 
Peritonitis,  tuberculous,  pathology  of, 

i.  50 
Perlsucht,  Emulsion  (P.  E.)  Spengler, 
ii.  356 
Tuberculin  (P.  T.  O.)  Spengler,  ii. 

355 
Vaccine,  Spengler,  ii.  355 
Perspiration  in  anaphylaxis,  ii.  160 
Petroff's  method  of  sputum  culture,  i. 

560 
Petruschky's  "Etappen  Method"  of 

using  tuberculin,  ii.  383 
Pharynx,    reflex    motor    and    sensory 
disturbances  in,  i.  214 
tuberculosis  of,  i.  46;  ii.  105 


Pharmacological  remedies,  and  prog- 
nosis, i.  654 
in  treatment  of  tuberculosis,  ii.  461 
Phillipi,   statistics  of  psychoneuroses, 

i.  158 
Phillip's  fermentation  method  of  ex- 
amining sputum,  i.  553 
Phrenics,  degenerative  changes  in,  i. 
167 
reflex  spasm  of,  causes  lagging,  i. 

403,  468 
reflex  stimulation  of,  from  lung,  i. 
403,  468 
Phthisical  chest,  i.  464 
Phthisiophobia,  ii.  490,  520 

spread  by  physicians,  ii.  521 
Physical    signs,    etiological   classifica- 
tion of,  in  early  pulmonary 
tuberculosis,  i.  394 
of   advanced  pulmonary  tuberculo- 
sis, i.  435 
Physical  types,  normal  variation  in,  i. 

OoS}    ooO 

Physician,  attitude  of,    towards    pa- 
tient, ii.  222 
confidence  in  methods  of,  aids,  ii. 

395 
how  often  see  tuberculous  patient, 

ii.  480 
in  relationship  to  prognosis,  i.  641 
must  be  candid  with  patient,  ii.  210 
must  cooperate  with  patient,  ii.  217 
optimism  of,  aids  in  cure,  ii.  206 
relationship  of,  to  patient,  ii.  208 
Physiological  adaptation,  man's  power 
of,  ii.  257 
to  altitude,  ii.  259 
to  climatic  changes,  ii.  258 
to  different     degrees    of    moisture 
and  altitude,  ii.  273 
Physiological  basis,  of  psychotherapy, 

ii.  392 
Physiological  facts  important  in  chest 

examination,  i.  319 
Pike,  effect  of  low  blood  pressure,  I. 
237 
mechanisms  involved  in  maintaining 
blood  pressure,  i.  236 
Pilomotor  muscles  supplied  by  sym- 

pathetics,  i.  176 
Pituitrin  in  treatment  of  hemorrhage, 

ii.   178 
Playgrounds  in  preventing  tuberculo- 
sis, ii.  515 
Pleura,  absorptive  power  of,  ii.  53 
cough  from,  i.  451 


686 


INDEX 


Pleura — Cont  'd 

thickening  of,  i.  497 

diagnosed  by  palpation,  cases  il- 
lustrating, ii.  555,  568 
Pleural  adhesions,  ii.  59 

description  of  changes  in  soft  tis- 
sues over,  ii.  59,  60 
Pleural  effusion,  in  advanced  tubercu- 
losis, i.  496 
in  artificial  pneumothorax,  ii.  439 
may  follow  pneumothorax,  ii.  84 
Pleurisy,  acute  fibrinous,  ii.  53 
cough  in,  ii.  54 
pain  in,  ii.   54 
acute  serofibrinous,  ii.  54 
diagnosis  of,  ii.  57 
dyspnea  in,  ii.  57 
pain  in,  ii.  56 
treatment  of,  ii.  49 
apical,  many  cause  no  pain,  ii.  49 
as  early  symptom  of  tuberculosis,  i. 
391 ;  ii.  58 
cases    illustrating,    ii.    536,    553, 
557,  559,  590,  596,  612,  632, 
659 
auscultation  in,  ii.  58 
complicating    pulmonary    infection, 

ii.  52 
diaphragmatic,  ii.  67 

abdominal  pain  in,  ii.  69 
neck  pain  in,  ii.  70 
referred  pain  in,  ii.  67 
spasm  of  muscles  in,  i.  455 
dry,    in    advanced    tuberculosis,    i. 

496 
early,  means  active  tuberculosis,  ii. 

50 
effusion  in,  shall  it  be  removed,  ii. 

58 
in  advanced  tuberculosis,  i.   460 
infection  in,  ii.  50 
inspection  in,  ii.  57 
makes  diagnosis  almost  certain,  i. 

607 
may  come  any  time  prior  to  heal- 
ing, ii.  564 
palpation  in,  ii.  57 
pathological  changes  in  intercostal 

muscles  in,  ii.  61 
percussion  in,  ii.  58 
preceding    definite    clinical    pulmo- 
nary tuberculosis,  ii.  49 
pathology  of,  i.  48 
wrongly  diagnosed  intercostal  neu- 
ralgia, ii.  49 


Pleuritis,  tuberculous,  ii.  49 
Pneumonia,   a  definite   air-borne   dis- 
ease   differs    from    tubercu- 
losis, i.  67 
acute  caseous,  case  illustrating,  ii. 

628 
caseous,  temperature   curve   of,   ii. 

133 
caused  by  hemorrhage,  ii.  177,  183 
differentiated  from  tuberculosis,  i. 

67 
artificial,  ii.  429 

amount  of  gas  injected  in,  ii.  436 
and  compensatory  emphysema,  ii. 

431 
beneficial  effects  of,  ii.  433 
complications  of,  ii.  439 
conditions  not  always  same  when 

performed,   ii.   430 
effect  in  compressing  lung,  ii.  430 
effects  produced  by,  ii.  307 
gas  embolism  in,  ii.  441 
in   treatment    of    hemorrhage,   i. 

653,    ii.    180 
indications  for,  ii.  442 
injury  to  lung  in,  ii.  441 
length  of  treatment  with,  ii.  437 
lessens  danger  of  spread  of  dis- 
ease, ii.  433 
lights  up  activity  in  the  lung,  ii. 

440 
pleural  effusion  in,  ii.  439 
results  of  treatment  with,  ii.  443 
site  of  puncture  for,  ii.  435 
technic,  ii.  434 
auscultation,  ii.  81 
bulging    of    intercostal    spaces    in, 

ii.  80 
cause  of,  ii.  74 
changes  in  position  of   diaphragm 

in,  ii.  79 
coin  sound  in,  ii.  81 
cough  in,  ii.  78 
dangers  of,  ii.  83 
diagnosis  of,  ii.  81 
diet    in,    ii.    87 

difficulties  of  diagnosis  in,  ii.  82 
difficult  of  diagnosis  when  patient 
not  previously  under  observa- 
tion, ii.  73 
does  not  depend  on  strain,  ii.  74 
dyspnea  in,  ii.  75 
effect  on  patient,  ii.  73 

sputum,  case  illustrating,  ii,  615 
emphysema  of  superficial  structures 
in,  ii.  441 


INDEX 


687 


Pneumonia — Cont  'd 

follows    necrosis    of    tubercle    near 
pleura,    case   illustrating,   ii. 
615 
heart  in,  ii.  78 

increases  respiratory  effort,  ii.  432 
inspection,    palpation    and    percus- 
sion in,  ii.  79 
loss  of  consciousness  in,  ii.  79 
may  relieve  toxemia,  ii.  83 
may  result  in  benefit  or  harm,  ii. 

83 
metallic  tinkling  in,  ii.  81 
morphine  in,  ii.   87 
offers  argument  against  mixed  in- 
fection, ii.  83 
often  undiagnosed,  ii.  73 
pain  in,  ii.  75 
pain  not   constant   symptom   in,  ii. 

74 
pleural  effusion  in,  ii.  84 
prognosis  in,  i.  633 
recurrent,   cases  illustrating,  ii.   85 
relief  of  symptoms  following,  case 

illustrating,  ii.  615 
rest  in,  ii.  87 

shifting  of  mediastinum  in,  ii.  79 
spontaneous,    cases    illustrating,    ii. 

574,  578 
sputum  in,  ii.  79 
succussion  sound  in,  ii.  81 
sudden    rise    of    temperature    and 

pulse  curves  in,  ii.  82 
symptoms  of,  ii.  74 

cases  illustrating,  ii.  615,  629 
in  spontaneous  and  artificial,  dif- 
fer, ii.  438 
temperature  in,  ii.  75 
treatment  of,  ii.  87 

case  illustrating,  ii.  630 
varieties  of,  ii.  82 
vocal  fremitus  in,  ii.  80 
x-ray  in,  ii.  81 
Posture,    effect    on    temperature,    ii. 

154 
Pratt,  class  work  of,  in  tuberculosis, 

ii.  221 
Predisposition  to  tuberculosis,  i.   117 
Pregnancy,    effect    on,    prognosis,    i. 
640 
tuberculosis,  ii.  623 

case  illustrating,  ii.  553 
Premenstrual  rise   in   temperature,  i. 

378;  ii.  149 
Present  illness  and  clinical  history,  i. 
365 


Prognosis,  acute  caseous  tuberculosis, 
in,  i.  630 
age  in,  i.  624 
bacilli,  form  of,  in,  i.  634 

presence  of,  in,  i.  633 
blood,  condition  of,  in,  i.  639 
change  of  occupation  in,  i.  655 
character  of  lesion  in,  i.  628 

treatment  in,  i.  641,  644 
chronic    ulcerative    tuberculosis    In, 

i.  629 
circulatory  system  in,  i.  638 
climate  in,  i.  647 
constitution  in,  i.  625 
diazo  reaction  in,  i.   639 
digestive  system  in,  i.  637 
earliness  of,  diagnosis  in,  i.  642 

treatment  in,  i.  642 
economic  status  in,  i.  626 
environment  in,  i.  626 
fibroid  tuberculosis  in,  i.  629 
food  in,  i.  649 
heliotherapy  in,  i.  648 
hydrotherapy  in,  i.   649 
in    pulmonary   tuberculosis,   i.    624 
induced  pneumothorax  in,  i.  653 
mental  state  in,  i.  628 
miliary  tuberculosis  in,  i.  628 
nervous  system,  condition  of,  in,  i. 

636 
non-tuberculous  complications  in,  i. 

636 
open  air  in,  i.   646 
patient,  cooperation  of,  in,  i.  642 
pharmacological  remedies  in,  i.  654 
physician,  importance  of,  in,  i.  641 
pleurisy   in,   i.   632 
pneumothorax  in,  i.  633 
pregnancy  in,  i.  640 
psychotherapy  in,  i.  651 
respiratory  system  in,  i.  636 
rest  and  exercise  in,  i.  650 
sanatorium  vs.  home  treatment  in, 

i.  645 
tuberculin  in,  i.  652 
tuberculin  reaction  in,  i.  635 
tuberculosis  of  intestines  in,  i.  632 
tuberculosis  of  larynx  in,  i.  631 
tuberculous  complications  in,  i.  631 
tuberculous  meningitis  in,  i.  633 
urochromogen  reaction  in,  i.  639 

Program,  for  home  treatment,  ii.  476 
for  sanatorium  treatment,  ii.  500 

Prophylaxis,  ii.   503 

Prostate,  tuberculosis  of,  ii.  103 


688 


INDEX 


Protargol   in   laryngeal   and   pharyn- 
geal irritation,  ii.  448 
Protein,  an  important  element  of  diet, 

ii.  309 
Protein,  baeillary,  in  the  production  of 
fever,  ii.   122 

discussion  of  fever  caused  by,  ii. 
118 

from  whatever  source  produces  same 
toxic  syndrome,  ii.  342 

in  causation  of  fever,  ii.  114,  116 

may  be  followed  by  either  toxemia 
of  anaphylaxis,  ii.  161 

peripheral  irritation  of  vagus  by, 
causes  asthma,  ii.  165 

symptoms  from,  produced  by  small- 
er   dose    in    sensitized    than 
in  non-sensitized  animals,  ii. 
344 
Protein  poisoning,  caused  by  contam- 
ination of  distilled  water,  ii. 
179 
Psychasthenia,  ii.  390 
Psychoneuroses,  i.  151,  158 
Psychoses,  i.  150 

pathology  of,  i.  159 
Psychotherapy,  ii,  387 

a  positive  optimism,  ii.  388 

acts  by  improving  general  resist- 
ance, ii.  395 

an  individual  therapy,  ii.  390 

applied  to  tuberculosis,  ii.  392 

for  poor  eaters,  ii.  400 

helps  patient  cure  self,  ii.  389 

importance  of,  in  treatment  of  tu- 
berculosis, ii.  206 

improves,  appetite,  ii.  394 
digestion,  ii.  394 
prognosis,  i.  651 

most  generally  applicable  of  all 
remedies  to  chronic  tubercu- 
losis, ii,  394 

physiological  basis  for,  ii.  392 

presupposes  analyzing  each  patient, 
ii.  391 

relieves  effects  of  depressive  emo- 
tions, ii.  389 

relieves  inhibitory  action  of  sym- 
pathetics,  ii.  394 

technic  of  application  in  tubercu- 
losis, ii.  396 

treats  patient  as  individual,  ii.  388 
Pulmonary  tissue   especially   adapted 
to    the    tubercle   bacillus,    i. 
122 


Pulmonary  tuberculosis,  percentage  of 
bovine  and  human  infection 
in,  i.  59 
prognosis  in,  i.  624 
Pupil,    dilatation    of,    in    pulmonary 
tuberculosis,  i.  402 
sympathetic  and  greater  vagus  ac- 
tion on,  i.  198 
Pulse,  acceleration  of,  during  toxemia 
in  early  tuberculosis,  i,  381 
character  of,  in  tuberculosis,  i.  230 
effect    of     vagus    stimulation    on, 

case  illustrating,  ii.  646 
in  tuberculous  enteritis,  ii.  42 
persistently  rapid,  i.  443 
rapid,  explanation  of,  i.  231 
slowed  by  intestinal  infection,  case 

illustrating,  ii.  618,  658 
slowing  of,  due  to  reflex  stimula- 
tion of  vagus,  ease  illustrat- 
ing, ii.  654 
following  use  of  tuberculin,  case 
illustrating,  ii.  548 
Pyogenic  organisms,  not  cause  of  ne- 
crosis, i.  48 

E 

Rain,  and  open  air,  ii.  252 
Rales,  crepitant,  i.  480 

decrease  of,  as  healing  takes  place, 

i.  481 
extrapulmonary,  i.  482 
localized   over   areas   of    softening, 
i.  481 
Ranke,  divides  tuberculosis  into  three 

stages,  i.  357 
Ravenel,  feeding  experiments,  i.  69 
historical    sketch    of    ingestion   tu- 
berculosis, i.  75 
Reaction,  after  baths,  ii.  406 
immunity,  tuberculin  an,  i.  503 
prompt  maximum  means  active  le- 
sion, i.  601 
tuberculin,  ii.  336 
focal,  ii.  340 

not  excessive   in   advanced  tu- 
berculosis, ii.  350 
general,  ii.  337 
local,  ii.  338 
Recovery,  slow,  from   other  diseases, 

i.  365 
Reflex,  cause  of  asthma,  ii,  164 
kidney,  motor  and  sensory,  ii.  99 
motor  from  lung,  i.   454 
motor  to  diaphragm,  i.  403 


INDEX 


689 


Reflex— Cont'd 

motor,  in  tuberculous  enteritis,   ii. 

43 
sensory,  in  tuberculous  enteritis,  ii. 
43 
path,  of,  i.  454 
Reflex    changes,    in    soft   tissues,    re- 
gional   in    character,    i.    44, 
399,  405,  412,  467,  473;   ii. 
525 
Reflex  muscle  changes  due  to  patho- 
logical degeneration  and  oc- 
cupation,   i.    333,    405,    413, 
475 
Reflex  pathological  changes,  in  chest 

muscles,  i.  44,  406 
Reflex  spasm,  and  degeneration  in  di- 
agnosis, i.  399,  466 
of   muscles    difficult    to    detect    at 
times,  i.  467 
Reflex  stimulation,  early  symptoms  of 
pulmonary    tuberculosis    due 
to,  i.  366,  384 
symptoms    of,   in    advanced    tuber- 
culosis, i.  437  to  456 
Reflexes,  from  surface  to  viscera  and 

vice  versa,  ii.  401 
Remedies,  pharmacological  in  hemor- 
rhage, ii.  177 
Resistance,   decrease   in,   favors   clin- 
ical disease,  ii.  199 
general,    improved    by    psychother- 
apy, ii.  395 
improvement    in,    important    thera- 
peutic principles,  ii.  200,  508 
low,  at  time  of  puberty,  ii.  199 
Respiration,  and  nutrition,  ii.  328 
combined    thoracic    and    abdominal 

types  of,  i.  300 
diaphragmatic  type  of,  i.  299,  325 
muscles    involved    in,    i.    296,    324, 

327 
obstructed,    in    tuberculous    laryn- 
gitis, ii.  26 
thoracic  type  of,  i.  298 
Respiratory     compensation,     in     new 

born,  i,  128 
Respiratory  effort,  increased  by  pneu- 
mothorax, ii.  432 
Respiratory  note,  conditions  affecting, 
i.  429 
effect  of  muscles  and  subcutaneous 

tissue  on,  i.  428 
in  early  tuberculosis,  i.  429 
Respiratory  sounds,   character  of,  in 
early  tuberculosis,  i.  610 


Respiratory  sounds — Cont  'd 
quality  of,  in  advanced  tuberculosis, 

i.  479 
why   and  how  differ  in  early  pul- 
monary   tuberculosis,    i.    432 
Respiratory  system,  and  prognosis,  i. 
636 
changes    in,   in    advanced    tubercu- 
losis, i.  478 
Rest,  and  exercise  in  prognosis,  i.  650 
during  fever,  ii.  285 
during  hemoptysis,  ii.  288 
effect  of,  upon  cough,  ii.  291 
upon  the  heart,  ii.  289 
on  symptoms,  case  illustrating,  ii. 

627 
on    temperature,    ii.    287 
essential  to  life,  ii.  283 
few  people  know  how  to,  ii.  304 
for  lung,  ii.  204 

important    in    treating    every    case 

of  tuberculosis,  ii.   285,  296 

in    early    afebrile    tuberculosis,    ii. 

'     284 
in  neurasthenia,  ii.   530 
in  pneumothorax,  ii.  87 
in  treatment,  of  fever,  ii.  454 
of   tuberculosis,   i.    265;    ii.   277, 
282 
case   illustrating,  ii.   538,   545, 
604 
may  not  produce  desired  results,  ii. 

287 
mental,  in  hemorrhage,  ii.  176 
physical,  in  hemorrhage,  ii.  177 
physiology  of,  ii.  281 
relieves    the    patient    of    large    de- 
mands, ii.   284 
to  lung,  decreases  toxemia,  ii.  307 
produced    by    artificial    pneumo- 
.  thorax,  ii.  307 
toxins  disappear  during,  ii.  530 
when  dyspnea  is  present,  ii.  292 
when  nerve  exhaustion  is  present, 

ii.  294 
when  nutrition  is  low,  ii.  293 
Rest  hour,  ii.  203 
Rhomboidei,    innervation    of,    i.    296, 

328,  331 
Ribs,  inclination  of,  at  different  age 

periods,  i.  128 
Richard,  mechanical   shaker  for  spu- 
tum,   i.    554 
Right-handedness,  and  muscle  degen- 
eration, i.  405,  475 


690 


INDEX 


Rigidity  of  muscles  in  tuberculous 
meningitis,  ii.  90 

Riviere  and  Morland's  method  of  tu- 
berculin dosage,  ii.  361 

Roger,  method  of  studying  albumin 
reaction  in  sputum,  i.  538 

Rollier,  popularizes  heliotherapy,  ii. 
422 

Romer,  and  tuberculin  hypersensitive- 
ness,  i.  506 
and  tuberculin  reaction,  ii.  336 
incubation  period  in  tuberculosis,  i. 
65 

Room,   sanitary   arrangements  of,   ii. 
510 
should  be  sunny,  ii.  511 

Rosenow,  shows  bacteria  grown  on 
one  tissue  favors  same  in 
next  infection,  i.  32 

Ross,  emphasizes  sensory  disturbance 
of  skin,  i.  454 

Rothschild's  theory  of  diminution  of 
manubriosternal  angle,  i.  133 

' '  Roughing  it ' '  not  best  form  of  out- 
door life,  ii.   299 

Route  of  entry  of  the  tubercle  bacillus, 
practical  importance  of  its 
solution,  i.  30 

Russell,  studies  on  open  air,  ii.  230 


S 


Sahli,  congestive  type  of  hemorrhage, 

ii.  175 
Sajous,  Chas.  E.  de  M.,  Internal  se- 
cretions, i.  169 
Saliva,      sympathetic      and      greater 

vagus  action  on,  i.  211 
Salt  solution,  concentrated,  in  treat- 
ment of  hemorrhage,  ii.  179 
Sanatoria,  more  needed,  ii.  489 

undermanned,  ii.  486 
Sanatorium,    advantages    and    disad- 
vantages of,  ii.  481,  486,  490 
adverse  criticism  of,  ii.  485 
attendants  do  not  become  infected, 

ii.  519 
choice  of  patients  for,  ii.  495 
difficulty    of    feeding    patients    in, 

ii.  492 
no   danger  of  infection  in,  ii.  493 
results  of  treatment  in,  ii.  493 
sea  side,  for  children,  ii.  267 
should   have    an   efficient    head,   ii. 

487 
should  not  treat  en  masse,  ii.  487 


Sanatorium  treatment,  ii.  481 
and  prognosis,  i.  645 
contraindications  for,  ii.  497 
cost  of,  ii.  488 
length  of,  ii.  498 
program  for,  ii.  500 
Satterthwaite,    effect    of    toxemia   on 

heart  muscles,  i.  245 
Saugmann,    length    of    pneumothorax 

treatment,  ii.  437 
Scaleni,    in    diagnosis    of    pulmonary 
tuberculosis,  i.  401 
innervation  of,  i.  296,  327,  331 
Scapula,  altered  position  of,  i.  471 
Schafer,  endocrine  organs,  i.  169 
Schmorl's    theory    of    apical   furrow, 

i.  133 
Schools  in  prevention  of  tuberculosis, 

ii.  515 
Scrofula,  i.  108 
Sea  air,  and  tuberculosis,  ii.  265 

free  from  contamination,  ii.  266 
Season  influences,  in  treatment  of  tu- 
berculosis, ii.  273 
Sediment,  volume  in  sputum,  study  of, 

i.  537 
Segmental    innervation,     of     somatic 

muscles,  i.  329 
Segmental   relationship,    of   lungs,   i. 

179 
Segmentation,  of  body,  importance  of 

understanding,  i.  177 
Seminal   vesicles,   tuberculosis   of,   ii. 

103 
Sensitization,   cell,    degree   of,    deter- 
mined by  character  of  tuber- 
culin reaction,  i.  504 
effects  implantation,  i.   34,  119 
of  body  cells  to  tuberculin,  a  per- 
ipheral nerve  stimulation,  ii. 
342 
of  cells,   and   infection,  i.   34,   64, 
82,  89,  112;  ii.  337 
prevents    metastases,   i.    120;    ii. 
198 
Sensory  reflex  from  lung,  path  of,  i. 

454 
Sewall,     auscultation     of     whispered 
voice,  i.  434 
discussion  of  climate,  ii.  255 
relationship  of  short  bacilli  to  ac- 
tivity, i.  634 
Shadow,  normal  hilus  and  trunk,  in 

x-ray  plate,  i.  521 
Shadows,  trunk,  caused  by  blood  ves- 
sels or  bronchi,  i.  522 


INDEX 


691 


Shell  fish  poisoning,   due  to   anaphy- 
laxis, i.  157,  161 
Sherrington,    intergrative    action    of 

nervous  system,  i.   169 
Shock,  following  hemorrhage,  ii.  184 
Shoulders,  drooping  of,  i.  471 

pain   in,   as   symptom  of   intrapul- 

monary  disease,  i.  388,   452 

Skeletal  architecture,  variation  in,  i. 

335 
Skin,  areas  showing  sensory  changes, 
from  lung,  i.  454 
atrophy   of,    in    advanced   tubercu- 
losis, i.  466;  ii.  403 
blotching   and  itching  of,   in   ana- 
phylaxis,  ii.    160 
infection  through,  i.  80 
light  stimulates,  ii.  418 
mechanical  stimulation  of,  in  bath, 

ii.  408 
most  body  heat  eliminated  through, 

ii.  Ill 
pathological  changes  in,  i.  44 
regulates  heat  loss,  ii.  403 
should  be  active  in  tuberculosis,  ii. 

403 
stimulation  of,  influences  blood  and 
lymph  flow,  ii.  402 
Sleep,  ideal  physiological  rest,  ii.  281 

improved  by  open  air,  ii.  248 
Smegma,  differentiated  from  tubercle 

bacilli,  i.  559 
Smith,    Archibald,    initiates    altitude 
treatment  of  tuberculosis,  i. 
647 
Theobald,    and    question    of    inter- 
transmissibility  of  bacilli,  i. 
57 
Soiland,  Albert,  comparative  interpre- 
tation  of    x-ray    plates    and 
physical  diagnosis,  i.  526 
Solly,  discussion  of  climate,  ii.  254 
Spasm,  of  abdominal  muscles  in  tu- 
berculous enteritis,  ii.  43 
of   chest  and   neck  muscles   in   ac- 
tive tuberculosis,  i.  179,  332, 
398,  410,  466 
of  intercostal  muscles  in  acute  pleu- 
risy,  i.   496;    ii.  59 
of   lumbar  muscles   in  tuberculosis 
of  kidney,  ii.  98 
Specific    cellular    defense    and    infec- 
tion, i.  89 
Spengler,  and  artificial  immunization, 
ii.  335 


Spengler — Cont  'd 

suggests  use  of  bovine  tuberculin, 

ii.  356 

Spengler 's     method     of     designating 

dosage  of  tuberculin,  ii.  361 

staining  for  bacilli,  i.  557 

Sphincter  muscles,  innervation  of,  i. 

176 
Sphincters,  in  anaphylaxis,  ii.  160 
Spinal    fluid,    in   tuberculous    menin- 
gitis, ii.  91 
Splanchnic    congestion,    cause    of,    i. 
303 
in  advanced  tuberculosis,  i.  303,  439 
in  tuberculosis,  ii.  290 
Spleen,  tuberculosis  of,  i.  54 
Sponge,  cold,  ii.  407 
Spray  bath,  ii.  409 
Sputum,    absence    of,   though    cavity 
present,  ii.  557 
albumin  reaction,   diagnostic  value 
of,  i.  582 
in,  i.  538 

method  of  determining,  i.  539 
amounts  of,  vary  from  day  to  day, 

i.  534 
antiformin    method    of    examining, 

i.  556 
as   early  symptom   of  tuberculosis, 

i.  392 
bacilli,  disappearance  from,  i.  582 
free  and  bunched  in,  study  of,  i. 
545 
bacilli  in,  take  stain  differently,  i. 

542 
care  of,  in  home,  ii.  477 
collection  of,  i.  534 
cytological   examination   of,  i.   536 
daily  variation  in  bacilli  in,  when 

numbers  low,  i.  549 
dangers  from  dried,  i.  563 
decreases    following   pneumothorax, 

case  illustrating,  ii.  615 
direct  smear,  method  of  preparing, 

i.  552 
distribution  of  bacilli  in,  i.  540 
Ellermann   and    Erlandsen,   technic 

for  examination  of,  i.  551 
examination  of,  for  bacilli,  stand- 
ardization of,  i.  541 
in  diagnosis  of  pulmonary  tuber- 
culosis, i.  534 
factors  causing  amounts  of,  to  vary, 

i.  459 
fermentation  of,  prior  to  examina- 
tion, i.  537,  553 


692 


INDEX 


Sputum — Cont  'd 

from  cavity,  slow  to  disappear,  ii. 

564 
Gram-positive,     but     non-acid-fast- 

forms  in,  i.  559 
homogenization  of,  value  of,  i.  552 
importance  of  examining,  i.  458 
in  advanced  tuberculosis,  i.  458 
in  early  diagnosis    of    tuberculosis, 

i.  607 
in  pneumothorax,  ii.  79 
lymphocyte  count,  diagnostic  value 

of,  i.  582 
mechanical  shaker,  in  examination 

of,  i.  554 
Much's  granules  in,  i.  559 
mucus  in,  method  of  removing,   i. 

539 
number  of  bacilli  in,  in  24  hours, 

i.  561 
sediment  volume,  directions  for  de- 
termining, i,  537 
error  in  method,  i.  538 
value  of  study  of,  i.  537,  591 
should  always  be  examined,  ii.  214 
staining  for  bacilli,  i.  556 
straining  for    cytological  examina- 
tion of,  i.  536 
swallowing  of,  when  not  raised,  i. 

459 
technic  for  preparation  of,  for  ex- 
amination, i.  549 
time  of  search  for  bacilli,  impor- 
tant, i.  540,  543 
twenty-four  hour  sample  of,  advan- 
tage of,  i.  534 
wet  method   of   preparing   for  ex- 
amination, i.  556 
Stain,  factors  interfering  with  bacilli 

taking,  i.  541 
Staining,    advantages    of    Spengler's 

method,  i.  558 
Stains,  for  bacilli,  i.  556 
Starling,  showing  normal  elimination 

of  body  heat,  ii.  Ill 
Stasis,  intestinal,  factors  operating  to 
cause,  in  tuberculosis,  i.  268 
ill  effects  of,  upon  patient,  i.  268 
in  tuberculosis,  i.  266 
treatment  of,  i.  268 
normal    points    of,   in   intestine,   i. 
267 
State,  part  of,  in  preventing  tuber- 
culosis, ii.  514 
Statistics,  of  different  observers  not 
comparable,  ii.   386 


Steinert,  reports  degeneration  in  as-  ' 

cending  fibers  of  cord,  i.  167 
Sternocleidomastoideus,    in    diagnosis 
of  pulmonary  tuberculosis,  i. 
401 
innervation  of,  i.  296,  327,  330 
Sthenic  type  of  individual,  character- 
istics of,  i.  349,  354 
Stethoscope,  i.  427 

Stomach,  atony  and  dilatation  of,  in 
tuberculosis,  i.  258,  262 
dilatation   of,  case   illustrating,  ii. 
618 
symptoms  of,  i.  263 
symptoms  accompanying,  case  il- 
lustrating, ii.  647 
treatment  of,  i.  263 
case  illustrating,  ii.  647 
disturbances  of,  in  tuberculosis,  i. 

257 
reflexly  stimulated  by  inflammation 

of  lung,  i.  215 
sympathetic  and  vagus  action  on,  a. 
215 
Stool,  bacilli  in,  i.  52 

in  tuberculous  enteritis,  ii.  41 
Strength,  loss  of,  in  advanced  tuber- 
culosis, i.  438 
part  of  syndrome  of  toxemia,  ii. 
110. 
Streptothricosis,    differentiated    from 

tuberculosis,  i.  621 
Stricture  in  tuberculous  enteritis,  ii. 

38 
Subcutaneous  tissue,  condition  of,  al- 
ters palpation,  i.  398 
alters  percussion,  i.  398 
degeneration  of,  cause  of,  i.  399 
in  advanced  tuberculosis,  i.   466 
in   chronic   tuberculosis,   case   il- 
lustrating, ii.  525,  535,  543, 
554,  567,  580,  610,  622,  633 
lowers    percussion    note    and   de- 
creases resistance,  i.  477 
effect  of  occupation  on,  i.  333,  406 
influence    on    physical    findings,    i. 

332 
regional     degeneration    of,    means 
chronicity,  i.   399,  405,  466, 
473 
Suggestion  in  treatment,  i.  156   (see 

Psychotherapy) 
Sulci,  pulmonary,  position  of,  i.   321 
Sun,  physical  condition  of,  ii.  414 
Superinfection,  i.   359 


INDEX 


693 


Suspiciousness     of     tuberculous     pa- 
tients, i.  157 
Sweat    glands,  muscles    of,   supplied 

by  sympathetics,  i.  176 
Sweating,  a  result  of  toxemia,  i.  371, 
445 ;  ii.  450 
part    of   syndrome    of   toxemia,  ii. 

110 
part  of  vagus  syndrome,  i.  371,  445 
Sweats,  night  or  sleep,  ii.  449 
night,  treatment  of,  ii.  451 
Swimming,   followed  by  hemorrhage, 
ii.  300 
not    permitted    in    tuberculosis,    ii. 
300,  410 
Sympathetic    inhibition,    relieved    by 

psychotherapy,  ii.  394 
Sympathetic  nervous  system,  i.  170 
Sympathetic  reflex,  due  to  peripheral 

irritation,  i.  604 
Sympathetic   system  and  ovarian   se- 
cretion, i.  195 
grouping  of  structures  supplied  by, 

i.  175 
peculiarities  of,  i.  170,  172 
Sympathetics,  action  of,  upon  heart, 
i.   230 
and  digestive  tract,  i.  254 
central     stimulation     of,     produces 
toxic  group  of  symptoms,  i. 
231,  604 
characteristics  of  action  of,  i.  227 
conditions  which  irritate  in  tuber- 
culosis, i.  223 
effect  on  digestive  tract,  i.  440 
heart  and  blood  vessels,  i.  175,  199, 

232;    ii.    110,    551 
in  the  production  of  temperature, 

ii.  116 
stimulation  of,  causes  syndrome  of 

toxemia,  ii.  110 
supplying  lung,  i.  180 
Symptoms,  absence  of,  does  not  mean 
pathological  healing,  ii.  564 
blood  spitting,  in  classification  of, 

ii.  169 
cessation  of,  not  synonymous  with 

healing,  ii,  194 
classification  of,  cases  illustrating, 

ii.  525,  534 
clinical,    of    early    tuberculosis,    i. 

357 
depend  on  vagus  nerve  tonus  of  in- 
dividual, ii.  161 


Symptoms — Cont  'd 

difference    in   early    and    advanced 
pulmonary     tuberculosis,     i. 
435 
do   not  indicate  seriousness  of  in- 
fection, case  illustrating,  ii. 
607 
due     to,     antagonistic     action     of 
greater    vagus    and    sympa- 
thetic systems,  i.  199 
depressive  emotions,  i.  189 
reflex  stimulation,  i.  226,  366,  384 
cases  illustrating,  ii.  525,  527, 
543,  567,  609,  621,  650,  659 
toxemia,  i.  226,  366;  ii.  110 
cases    illustrating,  ii.  537,  609, 

621,  631,  650,  659 
variable,  i.  368 
tuberculous  process  per  se,  i.  226, 
366,   390 
most  valuable  in  diagnosis,  i. 
606;  ii.  537 
early,  etiological  classification  of,  i. 

365 
etiological   classification  of,  i.   184 
case  illustrating,  ii.  525,  534,  543, 
554,  567,  591,  600,  610,  622, 
632,  651 
etiological    classification    of,    gives 
better  understanding  of  clin- 
ical disease,  i.  604 
illustrated,  i.  527,  528,  530 
influenced  by  internal  secretions,  i. 

194 
in  spontaneous  and  artificial  pneu- 
mothorax, differ,  ii.  438 
lightness  of,   not   in  keeping  with 

severity  of  case,  ii.  538 
no,  pathognomonic  of    tuberculosis, 

i.  598 
of   activity  do  not  mean  unfavor- 
able progress,  case  illustrat- 
ing, ii.  549 
of    advanced    pulmonary     tubercu- 
losis, i.  435 
etiological     classification     of,    i. 
436 
of  deficiency  in  inspiratory  act,  i. 

303 
of  failing  heart,  i.  248 
of    malignant    tumors    of    lung,    i. 

621 
of  pneumothorax,  cases  illustrating, 

ii.  615,  629 
of    reflex   origin,   not    constant,    i. 
385 


694 


INDEX 


Symptoms — Cont  'd 

of    toxemia,   first    group    to    disap- 
pear,    case     illustrating,    ii. 
564 
may  disappear  early,  ease  illus- 
trating, ii.  607 
of  toxic  group,  characteristic  of,  i. 
366 
importance  of,  i.  605 
of  toxic  origin,  dut  to  central  stim- 
ulation   of    sympathetica,    i. 
604 
of  tuberculous  enteritis,  ii.  39 
case  illustrating,  ii.  660 
not    pathognomonic,    case    illus- 
trating, ii.  644,  657 
of  tuberculous  laryngitis,  ii.  24 
of  tuberculous  meningitis,  ii.  89 
part   of   mechanism  of    defense,   i. 

217 
reflex,  do  not  disappear  early,  case 

illustrating,  ii.  607 
reflex,    point    away    from    lung,    i. 
384 
variable  in  character,  i.  606 
relationship    of,    to    greater    vagus 
and  sympathetic   systems,  i. 
183 
relative  value   of    different  groups 
in    early    diagnosis,    i.    393, 
603 
relief    of,    following    necrosis    and 
caseation,    case    illustrating, 
ii.  628 
toxic  group  of,  absence  of,  does  not 
mean  absence  of  activity,  i. 
606 
conditions   under   which   present, 
i.  605 
toxic,  prolonged  by  adrenin,  i.  605 
treatment  of,  ii.  445 
unrecognized  when  metastases  tak- 
ing place,  ii.  545 
variability     of,     when     vegetative 
nerves  are  concerned,  i.  176, 
187,  189,  385 
variable,    in    advanced    pulmonary 
tuberculosis,  i.  435 
Syndrome,  of  anaphylaxis,  ii.  159 
of  toxemia,  i.  221,  226 ;  ii.  110,  159 
and    anaphylaxis    contrasted,    ii. 

344 
and   general  tuberculin   reaction, 

ii.  342 
prolonged  by  wrong  living,  i.  367 


Syphilis,     pulmonary,     differentiated 
from  tuberculosis,  i.  618 

T 

Tactile  fermitus,  meaning  of,  i.  417 
Technic,   for   preparation  of    sputum 
for  examination,  i.  551 
importance   of,   in   applying   meas- 
ures in  treatment  of  tuber- 
culosis, ii.  205 
of  applying,  exercise,  ii.  295 
heliotherapy,  ii.  423 
hydrotherapy,  ii.  404 
open  air  treatment,  ii.  248 
psychotherapy,  ii.  396,  398 
Temperature,   and  tuberculin  test,   i. 
507 
atmospheric,  influence  of,  on  body, 

ii.  115,  143,  258,  275 
body,    effect    of,    humidity    on,    ii. 
143 
wind  movement  on,  ii.  143 
normal  regulation  of,  ii.  110 
case  illustrating  gradual  reduction 

of,  ii.  547 
characteristics  of,   during  toxemia, 

i.  371 
differs  on  two  sides  of  mouth,  ii. 

155 
diurnal  variation,  increased  in  in- 
testinal infection,  case  illus- 
trating, ii.  646 
diurnal  variation  in,  in  tuberculosis, 

ii.  125 
due  to  inflammation  of  lung  tissue, 

i.  392 
early  morning,  value  of,  ii.  127 
effect  of,  cough  on,  case  illustrat- 
ing, ii.  645 
ovarian  secretion   on,   case   illus- 
trating, ii.  639 
rest  on,  case  illustrating,  ii.  604 
elevation  of,  during  increased  activ- 
ity, ii.  572 
in  relation  to  tuberculin,  case  il- 
lustrating, ii.  642 
exercise  must  not  depend  upon  de- 
gree of,  ii.  297 
factors    influencing    taking    of,    ii. 

125 
how  long  hold  theromometer  in  tak- 
ing, i.  376,  378 
importance  of  early  morning,  i.  376 
in  acute  caseous  pneumonia,  case  il- 
lustrating, ii.   628 


INDEX 


695 


Temperature — Cont  'd 
in  pneumothorax,  ii.   75 
in  tuberculous,  enteritis,  ii.  42 
meningitis,  ii.  89 
patient,  easily  influenced,  ii.  123 
increased  by  coughing,  ii.  573 
increased  diurnal    variation    in,    ii. 
550 
due  to  increased  toxemia,  case  il- 
lustrating, ii.  639 
indicative  of  moderately  active  tu- 
berculosis,   case    illustrating, 
ii.  636 
instructions  for  taking,  i.  376,  508 

ii.  124 
large  meal  raises,  ii.  115 
marked  rises  in,  caused  by  cough, 

case  illustrating,  ii.  616 
maximum  and  minimum,  keep  pace 
with  body  activities,  ii.   109 
muscular  exercises  raises,  ii.  115 
nervous  influences  in,  i.  380 
normal  diurnal  variation  in,  ii.  125 
pneumonic  type  of,  ii.  550 
premenstrual,  menstrual,  and  post- 
menstrual,  i.  378,  380 ;  ii.  149 
rise  in,  during  toxemia,  i.  371 
slight  persistent  rises  in,  not  always 

due  to  tuberculosis,  i.  381 
subnormal,  cause  of,  ii.  121 

part  of  syndrome  of  toxemia,  ii. 
110 
sudden  rise  of,  in  pneumothorax,  ii. 

82 
value  of,  in  early  diagnosis,  i.  607 
wide  diurnal  variation  in,  as  result 
of   intestinal   infection,   case 
illustrating,   ii.   655 
shows  marked  vasomotor  disturb- 
ances, ii.  646 
Temperature  curve,  always  above  nor- 
mal for  time  of  day,  case  il- 
lustrating, ii.  636 
and  nervous  influences,  ii.  146 
and  toxemia,   ii.  142 
characteristics  of,  in  tuberculin  re- 
action, i.  512 
effect  of  exercise  on,  ii.  148 
effect  of  menstruation   on,   case   il- 
lustrating, ii.  559 
factors  influencing,  ii.  154 
in  chronic   fibro-ulcerative   tubercu- 
losis, ii.  129 
in  tuberculosis,  factors  affecting,  ii. 
124 


Temperature  curve — Cont  'd 

influenced  by,  complications,  ii.  146 
gastrointestinal    disturbances,    ii. 

146 
other  factors  than  toxemia,  ii.  142 
menstrual,  influenced  by  pelvic  in- 
flammation, case  illustrating, 
ii.  637 
of  acute    miliary     tuberculosis,    ii. 

128 
of  caseous  pneumonia,  ii.  133 
of  chronic     fibro-ulcerative     tuber- 
culosis,   case   illustrating,   ii. 
640 
of  early  tuberculosis,  ii.  126 
of  inactive  tuberculosis,  ii.   139 
of  intermittent  toxemia,  ii.  133 
of  severe  toxemia,  ii.  138 
valuable,  in  giving  idea  of  type  of 

toxemia,  i.  373 
waves  in,  due  to  activity,  case  illus- 
trating, ii.  614 
Temperature  fall  in,  in  anaphylaxis, 

ii.  160 
Temperature    measurements,  accuracy 

in,  essential,  ii.  124 
Tendeloo  's  law,  i.  146 
Tendeloo  's   theory  that  lessened  mo- 
tion is  determining  factor  in 
localizing   pulmonary  metas- 
tases, i.  135 
Testicle,  tuberculosis  of,  ii.  102 
diagnosis  of,  ii.  102 
treatment  of,  ii.  102 
Thelinius'   method   of   using  mechan- 
ical shaker,  i.  555 
Therapeutics,    principles    underlying, 

ii.   186 
Thoracic  cavity,  compensatory  changes 

in,  i.  281 
Thoracic  organs,  compensation  in,  i. 

281 
Thorax,  bony,  compensation  in,  i.  293 
phthisicus,  not  a  predisposing  condi- 
tion, i.  142 
Throat  compress,  in  tuberculous  laryn- 
gitis, ii.  411 
Thyroid,  enlargement  of,  in  early  tu- 
berculosis, i.  194 
Thyroid  secretion,  influence  of,  i.  194 
Tissue  wasting,  effects  of,  i.  306 
Tissues,  adaptability  of,  factor  in  in- 
fection, i.  31 
density  of,  determined  by  palpation, 
i.  476 


696 


INDEX 


Tissues — Cont  'd 

lack  of  resistance  of,  on  palpation 

over  cavity,  i.  490 
Tongue,   atrophy  of,  in  tuberculosis', 

i.  214 
tuberculosis  of,  ii.  104 

treated  by  tuberculin,  ii.  385 
Tonsils,  as  portals  of  entry,  i.  73 
contain  tubercle  bacilli,  i.  73 
faucial  and  pharyngeal,  importance 

of,  in  defense  of  child,  i.  93 
natural  drainage  of,  i.  95 
tuberculosis  of,  i.  46 
Tonus,  muscular,  normal  variation  in, 

i.  336 
sympathetic,  predominates,  i.  193 
vagus,  at  times  present  during  tox- 
emia, i.  606 
greater  than  sympathetic,  i.  192 
in  digestive  tube,  i.  258 
predominates,  i.  193 
Toxemia,    absence    of    symptoms    of, 

does    not    indicate    healing, 

case  illustrating,  ii.  607 
action  of,  upon  heart,  i.  231 
acute,  injures  nerve  cells,  i.  221 
and  anaphylaxis,      contrasted,      ii. 

158,   341 
and  brain  cells,  i.  160 
and  nervous  system,  i.  151 
and  neurasthenia,  i.  158 
and  temperature  curve,  ii.  142 
causes  sweating,  ii.  450 
characteristics  of  symptoms  due  to, 

i.  366,  368 
decreases  appetite  and  digestion,  ii. 

285 
due  to  intestinal  stasis,  i.  268 
early  symptoms   of  pulmonary  tu- 
berculosis due  to,  i.  366 
effect  on  heart,  i.  245 

case  illustrating,  ii.  618 
fever  an  index  to,  ii.  129 
fever  part  of  syndrome  of,  ii.  108, 

452 
importance  of  symptoms  due  to,  i. 

605 
increased  by  exercise,  ii.  284 
intermittent,  temperature  curve  of, 

ii.  133 
periods  of,  not  necessarily  serious, 

ii.  575 
reduces  nutrition,  ii.    327 
relationship  to   internal   secretions, 

i.   366 
relieves  asthma,  ii.  161,  167 


Toxemia — Cont  'd 

severe,   produces   vasomotor    paral- 
ysis, ii.  345 
temperature  curve  of,  ii.  138 
symptoms  due  to,  in  advanced  tu- 
berculosis, i.  437 
symptoms  of,  ii.  110,  159,  527 
case  illustrating,  ii.  537,  549,  590, 

600,  609,  613 
marked,  case  illustrating,  ii.  546 
syndrome  of,  i.  221;  ii.  159 

and   general  tuberculin  reaction, 

i.  511 ;  ii.  342 
prolonged  by  wrong  living,  i.  367 
Toxic  reaction,  not  an  immunity  reac- 
tion, ii.  341 
Toxins,  act  centrally,  i.  223 
affect  nervous  system,  i.  108 
and  blood  pressure,  i.  236 
constant  action  of,   disturbs  nerve 

quilibrium,  ii.  390 
continually  bombard  brain  in  active 

tuberculosis,  ii.  393 
injure   nerve  cells,  ii.   392 
may  produce  hemorrhage,  ii.  174 
Trapezius  muscle,  change  in  contour 
of,  of  diagnostic  importance, 
i.  407,  467 
in   diagnosis    of   pulmonary   tuber- 
culosis, i.  401 
innervation  of,  i.  296,  328,  331 
Trauma,  relationship  of,  to  tubercu- 
losis, i.  313 
Traumatic  tuberculosis,  i.  312 
Treatment,  active,  in  tuberculosis,  ii. 
193 
arsenic  in,  ii.  465 
artificial  pneumothorax  in,  ii.  429 
atropin  in,  ii.  469 
bromides  in,  ii.  468 
case  illustrating  result  of,  ii.  532 
character  of,  and  prognosis,  i.  644 
characteristics    of,    valuable    meas- 
ures in,  ii.  203 
codliver  oil  in,  ii.  467 
cold  sponge  in,  ii.  407 
cooperation  in,  depends  on  intelli- 
gence, ii.  220 
cost  of  sanatorium,  ii.  488 
creosote  in,  ii.  463 
definiteness  essential  to  success  in, 

ii.  204 
earliness  of,  and  prognosis,  i.  642 
effect  of  light  in,  ii.  421 
entertainment  not  a  necessity  in,  ii. 
300 


INDEX 


697 


Treatment — Cont  'd 

haphazard,   proves   disastrous,   case 

illustrating,  ii.  636 
heliotherapy  in,  ii.  414 

technic,  ii.  423 
home,  ii.  470 

and  prognosis,  i.  645 
hydrotherapy  in,  ii.  401 
hypophosphates  in,  ii.  467 
importance  of  prolonged,  case  illus- 
trating, ii.  563 
improved  natural  resistance,  import- 
ant principle  in,  ii.  200 
intelligent  guidance  most  important 

factor  in,  ii.  254 
intelligent,    requires    knowledge    of 
pathological  condition,  ii.  287 
intensive,  ii.  500 
interruption  of,  ii.  383 
iodine  in,  ii.  465 
iron  in,  ii.  468 
length  of  sanatorium,  ii.  498 
length  of  tuberculin,  ii.  382 
length  of,    with    artificial    pneumo- 
thorax, ii.  437 
method    of,    more    important    than 

measure,  ii.  206 
most  valuable  measures  in,  act  in- 
directly, ii.  202,  209 
of  atonic  constipation,  i.  271 
of  cough,  ii.  447 

wet  jacket  in,  ii.  411 
of  failing  heart,  i.  249 
of  fever  by  air  baths,  ii.  455 
of  hemorrhage,  ii.  175 

case  illustrating,  ii.  617 
of  insomnia,  ii.  459 
of  intestinal  stasis,  i.  268 
of  night  sweats,  ii.  451 
of  pain,  ii.  457 

in  tuberculous  enteritis,   case  il- 
lustrating, ii.  648 
of  pneumothorax,  ii.  87 

case  illustrating,  ii.  630 
of  spastic  constipation,  i.  275 
of  symptoms  of  tuberculosis,  ii.  445 
of  tuberculosis,  cold   air  in,  ii.   272 
depends  on  close  detail,  ii.  222 
importance  of  psychotherapy  in, 

ii.  206 
proper  mental  attitude  in,  ii.  205 
rational  basis  of,  ii.  188 
rest  and  exercise  in,  ii.  282 
of  tuberculosis   of  bladder,  ii.   101 
of  tuberculosis  of  kidney,  ii.  100 
of  tuberculous  laryngitis,  ii.  28 


Treatment  of  tuberculous  laryngitis — 
Cont'd 
case  illustrating,  ii.  630 
compresses  in,  ii.  31 
medicinal  measure  in,  ii.  29 
rest  to  larynx  in,  ii.  31 
of  tuberculous  meningitis,  ii.  91 
open  air,  technic  of,  ii.  248 
pathological  changes  must  be  borne 
in   mind    during,   case   illus- 
trating, ii.  640 
pharmacological  remedies  in,  ii.  461 
program    for,   case   illustrating,   ii. 

592 
remedies  with  general  action  in,  ii. 

463 
requirement  of  measures  in,  ii.  201 
results    of    artificial    pneumothorax 

in,  ii.  443 
results  of  sanatorium,  ii.  493 
sanatorium,  ii.  481 

and  prognosis,  i.  645 
spray  bath  in,  ii.  409 
success  of,  depends  on  close  medical 

guidance,  ii.  223 
technic  of    artificial    pneumothorax 

in,  ii.  434 
technic  of  using  psychotherapy  in, 

ii.   396,   398 
tepid  sponge  in,  ii.  410 
tuberculin,  choice  of   patients  for, 
ii.  351 
effects  of,  ii.  384 
indications  and  contraindications 

for,  ii.  352 
when  withhold,  ii.  362 
value  of  remedies  employed  in,  rel- 
ative, ii.  206 
value  of  tuberculin  in,  ii.  202 
Trional  in  insomnia,  ii.  459 
Trudeau,  and  artificial  immunization, 

ii.  335 
Trudeau    school    for    tuberculosis,   ii. 

379 
Tubercle,   caseation   and   rupture   of, 
case  illustrating,  ii.  573 
conglomerate,  i.  27 
conversion  into  fibrous  tissue,  i.  26 
formation  of,  i.  25 
growth  of,  i.  26 

necrosis     and     caseation     of,     fol- 
lowed   by    hemorrhage,    case 
illustrating,   ii.   614 
necrosis  of,  i.  26 
protein  an  antigen,  ii.  336 


698 


INDEX 


Tubercle— Cont'd 

softening  and  expulsion  of,  follow- 
ed by  relief  of  symptoms, 
case  illustrating,  ii.  613 

symptoms    following    caseation    of, 
case  illustrating,  ii.  559 
Tubercle  bacilli,  bunches  of,  in  urine, 
i.  574 

careful  technic  necessary  for  com- 
parison of,  i.  565 

disappearance  of,  from  sputum,  i. 
582 

frequency  of,  in  feces,  i.  579 

in  feces,  does  not  mean  bowel  in- 
fection, i.  579 

in  feces,  when  no  sputum  raised, 
i.  580 

in  urine,  method  of  examining  for, 
i.  574 

length  of  index  for,  i.  567 

lengths  of,  method  of  determining, 
i.  565 

method  of  examining  for,  in  feces, 
i.  579 
Tubercle  bacillus  vaccine   (T.  B.  V.) 

Spengler,  ii.  355 
Tuberculin,  ii.  329 

administration  of,  controlled  by 
careful  physical  examination, 
ii.  379 

administration  of,  presupposes  a 
knowledge  of  the  clinical 
course  of  tuberculosis,  ii. 
380 

aids  in  absorption  of  pleural  ef- 
fusion, ii.  59 

an  immunity  reaction,  ii.  341 

and  physical  examination,  ii.  382 

and  prognosis,  i.   652 

animal  experiments  with,  inconclu- 
sive, ii.  333 

apparatus  for  making  dilutions,  ii. 
357 

Beraneck,  ii.  355 

bovine,  ii.  356 

case  illustrating  employment  of,  ii. 
532,  539 
in  advanced  tuberculosis,  ii.  576 

choice  of  patients  for  treatment 
with,  ii.  351 

choice  of  preparation,  ii.  357 

clinical  hypersensitiveness  to,  ii. 
347 

constantly  set  free  from  focus  of 
infection,  ii.  330 


Tuberculin — Cont  'd 

contraindication  for  use  of,  ii.  352 

difference  in  action  toward  human 
beings   and   animals,  ii.   334 

different  skins  react  differently  to, 
i.  601 

difficult  to   treat   active   tuberculo- 
sis with,  ii.  349 

dilution  for  subcutaneous  test,  i.  507 

dosage    in    different    types    of    the 
disease,  ii.  366 

dosage  of,  in  subcutaneous  test,  i. 
508 
must  be  considered  with  interval, 
ii.  370 

efficacy    of,  shown    in    tuberculous 
laryngitis,  ii.  384 
shown  in  tuberculosis  of  tongue, 
ii.  385 

failure  of  patient's  own  to  cure,  ii. 
347 

fibrosis  in  pulmonary  tuberculosis, 
hastened  by  its  use,  ii.  385 

focal  reaction  to,  ii.  340 

from  different  strains  of  bacilli  dif- 
fer, i.  601 

general    reaction    causes    syndrome 
of  toxemia,  ii.  342 

general  reaction  in,  ii.  337 

general   reaction   to,    due   to   toxic 
molecule,  ii.  337 

haphazard    administration    of,    not 
best,  ii.   365 

hypersensitiveness,     and     character 
of  lesion,  i.  505 
appears  with  focus,  i.  506 
diminishes  with  healing,  i.  506 
varies  with  virulence,  i.  506 

hypersensitive  reaction  to,  specific, 
i.  513 

importance  of,  graphic  chart  of  pa- 
tient during  treatment  with, 
ii.  381 
knowledge  of  pathological 
changes  when  administering, 
ii.  379 
observing  focal  stimulation  in,  ii. 
364 

in  circumscribed,  moderately  active 
tuberculosis,  ii.  367 

in  diagnosis  of  tuberculous  laryngi- 
tis, ii.  28 

indications  for  use  of,  ii.  352 

individualization    in    doses    of,    ii. 
366 

in  early  clinical  tuberculosis,  ii.  366 


INDEX 


699 


Tuberculin — Cont  'd 

in  moderately  active,  widespread  tu- 
berculosis, ii.  368 
in  moderately  advanced  slightly  ac- 
tive tuberculosis,   ii.   367 
interval  between  doses  varies  with 

size  of  dosage,  ii.  376 
intravenous    administration    of,    ii. 

363 
in    treatment    of,    tuberculosis    of 
bladder,  ii.  101 
tuberculous  kidney,  ii.  100 
tuberculous  ovary,  ii.  103 
in   widespread    active    tuberculosis, 

ii.  369 
in  widespread  moderately  active  tu- 
berculosis, ii.  368 
its  safety  for  general  use,  ii.  378 
Koch's  Old,  contains  greatest  num- 
ber    of     partialantigens,     i. 
506 
local  reaction  to,  ii.  338 
method  of  administering,  ii.  363 
method  of  designating  dosage  of,  ii. 

361 
method  of  diluting,  ii.  357 
method  of  dosage  of,  ii.  365 
must  be  supported  by  other  meas- 
ures, ii.  384 
necessary  for  cure  of  tuberculosis, 

ii.  330 
not  a  perfect  remedy,  ii.  202 
oral  administration  of,  ii.  363 
phenomena  following  injection  of, 

ii.  371 
poisonous  nature  of,  ii.  329 
preparations  commonly  used,  ii.  353 
produces  immunity,  ii.  330 
R.  Koch,  ii.  355 

relationship  of  dosage  to  tempera- 
ture elevation,  case  illustrat- 
ing; ii.  642 
schematic  illustration  of  action  of, 
ii.  346 
phenomena  following  injection  of, 

ii.  375 
phenomena      following     repeated 
small    dose    and    production 
of  toximmunity,  ii.  377 
scheme   for  administration,   ii.   372 
scheme  for  diluting,  ii.  359 
sensitization  to,  a  peripheral  nerve 

stimulation,  ii.  342 
site  of  injection,  ii.  364 
small  dose  of,  ii.  371 
stimulates  fibrosis,  ii.  332 


Tuberculin — Cont  'd 
stimulates  more  recent  tubercles  to 

healing,  ii.  349 
stop,  during  hemorrhage,  ii.  182 
time   of   day   for   injection   of,   ii. 

365 
use  of,  best  learned  by  observing 
those   who    give    it   well,    ii. 
379 
use  of,  in  acute  caseous,  case  illus- 
trating, ii.  627 
value  of,  in  treatment,  ii.  202 
variability  of,  i.  601 
what  is  designated  by,  ii.  329 
when  dose  should  be  given,  ii.  372 
when  withhold  during  treatment,  ii. 

352 
why  administration  of,  aids  cure,  ii. 

348 
withheld    during    complications,    ii. 

352 
withheld  during  hemorrhage,  ii.  352 
Tuberculin  reaction,  ii.  236 
and  anaphylaxis,  ii.  162 
and  prognosis,  i.  635 
antigen-antibody    reaction,    i.    503, 

513 
depends  on  reactive  ability  of  body 

cells,  i.  503 
focal,  i.  510 

why  not  present  in  necrotic  areas, 
ii.  348 
general,  i.  510 

diagnostic  value  of,  i.  511 
symptoms  of,  i.  510 
syndrome  of  toxemia,  i.  511 
in  larynx,  ii.  18 
local,  i.  509 

meaning  of  prompt  marked,  i.  504 
most  marked  during  activity,  i.  600 
prompt,  means  active  lesion,  i.  505, 

513 
temperature  curve  characteristic  of, 
i.   511 
Tuberculin  test,  concealed  tuberculo- 
sis and,  i.  504 
conjunctival,  i.  502 

positive  reaction,  i.   515 
cutaneous,  i.  512 

increases  our  knowledge  of  tuber- 
culous infection,  i.  502 
meaning  of  prompt  reaction  to, 

i.  504,   513,  600 
positive  reaction,  i.  514 
real  value  of,  i.  513 
rules  for  making,  i.  513 


700 


INDEX 


Tuberculin  test,  cutaneous — Cont'd 
strength  of  tuberculin  used  in,  i. 
514 

dilution  of  tuberculin  for  making, 
i.  507 

focal  reaction  in,  i.  510 

general  reaction,  i.  510 

importance   in    diagnosis,   i.    599 

in  moderately  advanced  active  tu- 
berculosis, ii.  536 

intradermal,  i.  515 

Koch's    Old    tuberculin   used    for,    i. 
506,  514 
percutaneous,  i.  515 
real  value,  generally  underestimated, 

i.  504 
reveals   frequency   of    infection   in 

childhood,  i.  100,  102 
should  be  made  carefully,  i.  514 
subcutaneous,  i.  506 

cases  applicable  in,  i.  508 
dosage  in,  i.  508 
positive  reaction  to,  i.  509 
temperature  in,  i.  507 
Tuberculin   treatment,   case   illustrat- 
ing, ii.  559 
effects  of,  ii.  384 
length  of,  ii.  382 
Tuberculins,  of  different  manufactur- 
ers compared,  i.  602 
Tuberculosis,  ability  of  medical  men 
to  cope  with,  improving,  ii. 
209 
acidosis  in,  i.  456 
active,  and  prompt  maximum  tuber- 
culin reaction,  i.  513 
can  x-ray  determine,  i.  518 
clinical    evidence    of,    case    illus- 
trating, ii.  604 
difficult  to  treat  with  tuberculin, 

ii.  349 
shows  most  marked  tuberculin  re- 
action, i.  600 
shows      waves      in      temperature 
curve,   .case    illustrating,    ii 
614 
treatment  in,  ii.  193 
without  syndrome  of  toxemia,  i. 
368 
activity  in,  means  multiplication  of 

bacilli,  ii.   190 
acute,  in  early  childhood,  i.  98 
in  small  animals,  ii.  335 


Tuberculosis — Cont  'd 

acute  caseous,  case  illustrating,  ii. 

621 
in   prognosis,   i.    630 
acute    miliary    temperature    of,  ii. 

128 
advanced,    acromion   process    in,   i. 

471 
anorexia  in,  i.  439 
appetite,  loss  of,  in,  i.  439 
auscultation  in,  i.  478 
blood  changes  in,  i.  437,  585 
bronchitis  in,  i.  460 
cavity  in,  i.  489 
changes  in  respiratory  rhythm  in, 

i.  478 
chests,  shape  of,  in,  i.  471 
circulatory     disturbances     in,     i. 

442 
colds  in,  i.  460 
compensatory    emphysema   in,    i. 

493 
contour  of  chest  wall  in,  i.  468 
cough  in,  i.  450 
difficult  to  heal,  ii.  201 
digestive  disturbances  in,  i.  439 
dry  pleurisy  in,  i.  496 
dyspnea  in,  i.  457 
endurance,  lack  of  in,  i.  438 
extension  from  primary  metasta- 
ses, i.  435 
extrapulmonary  rales  in,  i.  482 
fever  in,  i.  445 
fibrosis  in,  i.  488 
harsh  breathing  in,  i.  479 
heart  in,  i.  442 
hectic  flush  in,  i.  458 
hemoptysis  in,  i.  460 
hoarseness  in,  i.  447 
importance  of   careful   diagnosis 

in,  i.  435 
inspection  in,  i.  464 

case  illustrating,   i.   469 
larynx,  tickling  in,  i.  450 
malaise  in,  i.  438 
menstrual  irregularities  in,  i.  460 
metabolic  changes  in,  i.  440 
movement  of  chest  wall  in,  i.  468, 

475 
muscle    degeneration   in,   i.    466, 
,       473 

muscle  spasm  in,  i.  466,  473 
nausea  in,  i.  440 
nervous  system,  changes  in,  i.  150, 

168,  217 
night  sweats  in,  i.  445 


INDEX 


701 


Tuberculosis,  advanced — Cont  'd 

pains  in  chest  and  shoulders,  in, 

i.  452 
palpation  in,  i.  472 
percussion  in,  i.  477 
phthisical  chest  in,  i.  465 
physical  examination  in,  i.  464 
pleural  effusion  in,  i.  496 
pleurisy  in,  i.  460 
prolonged  expiration  in,  i.  478 
pulmonary  infiltration  in,  i.  482 
quality  of  respiratory  note  in,  i. 

479 
rales  in,  i.  480 
rough  breathing  in,  i.  479 
scapulae  in,  i.  471 
shoulders,  drooping  of,  in,  i.  471 
skin,  atrophy  of  in,  i.  466 
sputum  in,  i.  458 
strength,  loss  of,  in,  i.  438 
subcutaneous  tissue,  atrophy  of, 

in,  i.  466,  473 
thickened  pleura  in,  i.  497 
toxic  symptoms  in,  i.  437 
trapezius,  outline  of,  in.  i.  467 
vomiting  in,  i.  440 
weight,  loss   of,  in,  i.  440 
advanced  cases,  rarely  loose  bacilli, 

i.  584 
advanced  pulmonary,  course  of,  un- 
even, i.  435 
etiological  classification  of  symp- 
toms in,  i.  436 
signs  and  symptoms  of,  i.  435 
affects  all  systems  of  body,  ii.  219 
air,    food    and    hygiene,   not    cures 

for,  ii.  203 
all  body  cells  sensitized  in,  ii.  337 
altitude  treatment  of,  initiated  by 

Archibald  Smith,  i.  647 
and  appetite,  i.  255 
and  asthma,  ii.  164 
and  chronic     purulent      bronchitis, 

differentiation  of,  i.  614 
and  climate,  ii.  254 
and  constipation,  i.  269 
and  definite  air-borne  diseases  com- 
pared, i.  67 
and  double  personality,  i.  150 
and  food,  ii.   308 
and  general   asthenia,  i.   612 
and  hypochlorhydria,    i.    259 
and  influenza,  differentiation  of,  i. 

614 
and  insanity,  i.  150 


Tuberculosis — Cont  'd 

and  intercostal  neuralgia,  differen- 
tiation of,  i.  613 
and  marriage,  ii.   516 
and  mental  attitude,  i.  153 
and  neurasthenia,   i.    158 
and  open  air,  ii.  227 
and  organic  heart  lesions,  i.  243 
and  overfeeding,  ii.  310 
and  sea  air,  ii.  265 
and  underfeeding,    ii.    314 
application    of    light    in   treatment 

of,  ii.   421 
Arneth's    classification    of    neutro- 

philes  in,  i.  577 
artificial    pneumothorax     in     treat- 
ment of,  ii.  429 
automobiling  in,  ii.  300 
belongs  to  general  medicine,  ii.  208 
blood  pressure  in,  i.  235,  303 
blood  spitting,  an  early  sign  of,  ii. 
169 
makes   diagnosis   of,   almost   cer- 
tain, ii.  170 
brachial  neuritis  in,  i.  161 
caseous,  characteristics  of,  i.  41 
cause  of  apathy  toward,  ii.  187,  208 
cause  of  fever  in,  ii.  286 
changes  in  neutrophile  in,  i.  577 
characteristics  of  valuable  measures 

in  treatment  of,  ii.  203 
chronic  fibro-ulcerative,  temperature 

curve  of,  ii.  129 
chronic,  periods  of  activity  in,  case 

illustrating,  ii.  548 
chronic  ulcerative,  and  prognosis,  i. 

629 
cleansing  bath  in,  ii.  412 
clinical,  early,  anemia  in,  i.  364 
blood  spitting  in,  i.  364 
bronchitis  in,  i.  364 
intercostal  neuralgia  in,  i.  364 
la  grippe  in,  i.  364 
malaria  in,  i.  364 
neurasthenia  in,  i.  364 
slow  recovery  from  disease  in, 
i.  365 
evidences  of  healing  in,  ii.  193 
in  adult,  a  metastatic  disease,  i. 

360 
present     illness,     importance     of 
careful  inquiry  into,  in  diag- 
nosis, i.  365 
present  without  fever,  i.  373 
close  medical  guidance  is  essential 
in,  ii.  223 


702 


INDEX 


Tuberculosis — Cont  'd 
clothing  in,  ii.  250 
Coccidioidal    granuloma,    differenti- 
ated from,  i.  621 
cold  air  in,  ii.  271 
cold  bath  in,  ii.  407 
cold  feet  in,  ii.  251 
colds  as  early  symptom  of,  case  il- 
lustrating, ii.  537 
colds  in,  i.  607 

compensatory  changes  in,  i.  281 
compensatory  emphysema  in,  i.  284 
concealed,  difficult  to  detect,  i.  504 
curability  of,  depends  on  physician, 
ii.  212 
judged  by  best  results,  ii.  188 
cured  in  all  climates,  ii.  261 
cure  of,  why  aided  by  tuberculin, 

ii.  348 
definite  technic  in  treatment  of,  ii. 

205 
definiteness  in  therapy  necessary  to 

success,  ii.  204 
determining  indican  in,  i.  572 
diagnostic  and  prognostic  values  of 
blood  findings  in,  i..  585 
urinary   findings   in,   i.    585 
diazo  reaction  in,  i.  569 
difference    in    symptomatology    of 

early  and  advanced,  i.  435 
differentiated   from,   actinomycosis, 
i.  620 
aspergillosis,  i.  621 
blastomycosis,  i.  621 
bronchiectasis,  i.   614 
bronchitis,  i.  613 
pneumonia,  i.  617 
pulmonary  infarct,  i.  616 
pulmonary  syphilis,  i.  618 
streptothricosis,  i.  621 
differs  at  different  age  periods,  i. 

96 
dilatation  of  stomach  in,  i.  262 
displacement  of  heart  in,  i.  283,  285 
diurnal    variation    in    temperature 

curve  in,  ii.  125 
duty  of  state  and  municipality  in 

preventing,  ii.  514 
early,  bronchitis  in,  i.  390 
cause  of  fever  in,  ii.  126 
character    of   respiratory    sounds 

in,  i.  610 
chest   and   shoulder   pains  in,   i. 

388 
circulatory  disturbances  in,  i.  387 


Tuberculosis,  early — Cont  'd 
cough  in,  i.  386 

diagnostic   importance   of   condi- 
tion   of    muscles    and    sub- 
cutaneous tissues  in,  i.  398, 
405 
digestive  disturbances  in,  i.  370, 

388 
feeling  of  being  run  down  in,  i. 

369 
flushing  of  face  in,  i.  389 
heals  readily,  ii.  200 
hoarseness  in,  i.  385 
increased  pulse  rate  in,  i.  381 
lack  of  endurance  in,  i.  369 
loss  of  strength  in,  i.  369 
loss  of  weight  in,  i.  370,  388 
malaise  in,  i.  369 
nervous  instability  in,  i.  369 
night  sweats  in,  i.  371 
percussion    changes   in,    i.   420 
pleurisy  in,  i.  391 
reflex  symptoms  in,  i.  384 
respiratory  sounds  in,  i.  429 
rise  in  temperature  in,  i.  371 
spitting  blood  in,  i.  390 
sputum,  i.  392 
symptoms  of,  i.  357 
temperature  curve  of,  ii.  126 
temperature  of,  that  of  continu- 
ous toxemia,  ii.  126 
urochromogen  reaction  in,  i.  570 
x-ray  in  diagnosis  of,  i.  611 
early  afebrile,  rest  and  exercise  in, 

ii.  284 
early   clinical,   a   metastatic    infec- 
tion, ii.  189 
in  adult,  ii.  506 
early  course    of,   case    illustrating- 

ii.  625 
early  lymphatic,   importance    of,   i. 

110 
early  pulmonary,     auscultation    in, 
i.   426 
clinical  symptoms  of,  i.  357 
harsh  breathing  in,  i.  433 
impeded  breathing  in,  i.  431 
physical  examination  of,  i.  394 
preceded  by  pleurisy,  ii.  49 
rough  breathing  in,  i.  430 
weakened  breathing  in,  i.  430 
whispered  voice  in,  i.  434 
why  respiratory  sounds  differ,  i. 
142 
effect  of,  displacement  of  heart  in, 
i.  292 


INDEX 


703 


Tuberculosis,  effect  of — Cont'd 
ozone  on,  ii.  263 
sea  air  on,  ii.  265 
upon  nervous  system,  ii.  392 
upon  heart,  i.  236 

enterocolitis    in,    i.    264 

exacerbation  of  symptoms  in,  case 
illustrating,  ii.   625 

examination  of,  blood  in,  i.  575 
feces  in,  i.  578 
sputum  in,  i.  534 
urine  in,  i.  568 

exertion,  greatest  cause  of  death  in, 
ii.  298 

extensive  with  little  necrosis,  case 
illustrating,   i.   606 

fact  of  being  considered  fatal,  hin- 
ders diagnosis,  i.  597 

factors  affecting  temperature  curves 
in,   ii.    124 

factors  reducing  efficiency  of  circu- 
lation in,  ii.  289 

failing  heart  in,  i.  248 

failure  of  patient's  own  tubercu- 
lin to  cure,  ii.  347 

family  history  in,  i.  361 

fever  in,  ii.  108 
irregular,  ii.  129 

fibrocaseous,  characteristics  of,  i. 
41 

fibroid,  characteristics  of,  i.  40 
takes  on  necrosis,  i.  41 

follows  crowded  condition,  ii.  270 

general  profession  fails  to  appreci- 
ate necessity  of  active  treat- 
ment in,  ii.  194 

glandular,    diagnosis    of,    i.    114 

graduated  exercise  in,  ii.  301 

healing  of,  and  temperature  curve, 
ii.  142 

heliotherapy  in  treatment  of,  ii. 
414 

hemorrhage  and,  i.  607.  ii.  168 

hemorrhage  as  early  symptom  of, 
ii.  542 

hidden  focus  of,  dangerous,  i.  599 

hidden,  importance  of,  i.  596 

high  grade  of  immunity  developed 
in,  ii.  330 

home  treatment  of,  ii.  470 

hopeful  attitude  of,  ii.  155 

horseback  riding  in,  ii.  299 

how  to  inform  patient  of  its  pres- 
ence, ii.  214 

hydrotherapy  in,  ii.  401 


Tuberculosis — Cont  'd 

ill  effects  of  use  of  hot  water  bot- 
tles in,  ii.  250 

immunity  in,  relative,  ii.  195 

importance  of,  proper  mental  atti- 
tude in  treatment  of,  ii.  205 
psychotherapy  in  treatment  of,  ii. 

206 
reflex  symptoms  in,  i.  606 
symptoms     due     to     tuberculosis 

process  per  se,  i.  606 
telling  patient   of,  ii.  213 

important  principles  of  healing  in, 
ii.   192 

improved  natural  resistance,  import- 
ant therapeutic  principle  in, 
ii.  200 

improves  slowly,  ii.  218 

inactive  temperature  curve  of,  ii. 
139 

incubation  period  in,  i.  65 

indigenous,  rare  in  arid  regions,  ii. 
269 

infection,  in  child,  ii.  505 

influenced  by  pregnancy,  ii.   553 

influence  of,  care  and  worry  on,  case 
illustrating,  ii.  638 
season  on  treatment  of,  ii.  273 

in  malaria,  i.  612 

in  neurasthenia,  i.  612 

insomnia   in,    ii.   458 

intensive  treatment  of,  ii.  500 

interest  in,  awakens  slowly,  ii.  186 

intermittent  toxemia  in,  ii.  133 

its  diagnosis  and  differential  diag- 
nosis, i.  596 

laryngeal,  throat  compress  in,  ii. 
411 

loss  of  motor  power  in,  ii.  393 

many  exacerbations  in  chronic,  ii. 
218 

meningitis  in,  ii.  88 

mental  power,  disturbed  in,  ii.  393 

method  of  using  x-ray  in,  i.  524 

miliary,  and  leucopenia,  i.  591 

miliary,  cause  of,  i.  40 

miliary,  following  hemorrhage,  ii. 
148 

mixed  infection,  not  common  in,  ii. 
122 

morbidity  and  mortality  in,  favored 
by  lowered  resistance,  ii.  200 

mortality  of,  greatest  from  15  to 
35  years,  ii.  200 

must  be  understood  by  general  pro- 
fession, ii.  187 


704 


INDEX 


Tuberculosis — Cont  'd 

must  have  the  aid  of  general  medi- 
cine, ii.  208 

nature  of,  ii.  195 

should  be  explained  to  patient,  ii. 
220 

no  single  cure  for,  ii.  254 

not  a  danger  in  general  hospital,  ii. 
518 

not   prevented   by   deep   breathing, 
ii.  305 

nutrition  in,  i.  252 

of  bladder,  ii.  101 

of  bones,  ii.  106 

of    colon,   resection   in,    case   illus- 
trating, ii.  654 

of  ear,   ii.    106 

of  genitourinary  system,  ii.  96 

of  glands,  pathology  of,  i.  54 

of  intestines,  ii.   33 
in  prognosis,  i.  632 

of  joints,  ii.  106 

of  larynx,  ii.   17 
in  prognosis,  i.  631 

of  liver,  pathology  of,  i.  53 

of  nose,  pathology  of,  i.  46 

of  ovary,  ii.  103 

of  pharynx,  ii.  105 
pathology  of,  i.  46 

of  pleura,  ii.  49 

of  prostate,  ii.  103 

of  seminal  vesicles,  ii.  103 

of  spleen,  pathology  of,  i.  54 

of  testicle,  ii.  102 

of  tongue,  ii.  104 

of  tonsils,  ii.  105 

pathological  changes  in,  i.  46 

of  tubes,  ii.  103 

open,  in  adult,  danger  of,  ii.  509 

open  air,  a  great  advance  in  treat- 
ment of,  ii.  228 
not  a  cure  for,  ii.  227 

pain  due  to  neuritis  in,  ii.  456 

patient  should  know  probable  course 
of,  ii.  397 

peripheral  nerves  in,  i.  160 

pharmacopeial  remedies  in,  ii.  461 

physical  examination  and  diagnosis 
of,  i.  608 

pleurisy  in,  i.  607 

pneumothorax  in,  ii.  73 

pneumothorax,  recurrent  in,  ii.  85 

pregnancy  in,  ii.  623 

prevailing  attitude  of  medical  pro- 
fession towards,  ii.  208 

primarily  a  lymphatic  disease,  i.  32, 


Tuberculosis — Cont  'd 

primarily  a  lymphatic  disease,  i.  52, 

55,  84,  112 
primarily  an  infection  of  childhood, 

i.  95 
principles    underlying    therapeutics 

of,  ii.  186 
prophylaxis  in,  ii.  503 
psychotherapy  in,  ii.  392 
wide  application  of,  ii.  394 
in  treatment  of,  ii.  387 
pulmonary,    activity     increased    by 
prolonged  strain,  case  illus- 
trating, ii.  644 
blood  borne,  i.  33 
diagnostic  value  of  changed  con- 
tour in  trapezius  muscle  in, 
i.    407 
lymph  glands  do  not  often  become 

enlarged  in   chronic,  i.   84 
not   diagnosed  when  bacilli  first 

enter  tissue,  i.  602 
relation  of  to  fistula  in  and,  cases 

illustrating,  ii.  653,  656 
x-ray  in  diagnosis  of,  i.  516 
rational  therapy  of,  ii.  188 
relation  of,  body  cells  to  nutrition 
in,  ii.  327 
trauma  to,  i.  313 
requirement  of  therapeutic  measures 

in,  ii.  201 
rest  and  exercise  in,  ii.  277 

in  treatment  of,  ii.  282 
rest  important  in  every  case  of,  ii. 

285 
"roughing  it"  in,  ii.  299 
sanatorium  treatment  in,  ii.  481 
severe  toxemia  in,  ii.  138 
shifting  of  trachea  in,  i.  289 
similarity   to    syphilis  in   stages,   i. 

357 
skin  should  be  kept  active  in,  ii.  403 
small  lesions   of,  most  curable,  ii. 

190 
spontaneous  healing  of,  ii.  191,  193 
spray  bath  in,  ii.  409 

produce  little  harm,  ii.  191 
specialists    in,    favor   active    treat- 
ment, ii.  193 
spread  of,  favored  by  lessened  re- 
sistance, ii.  199 
sputum  in  early  diagnosis  of,  i.  601 
statistics  of  different  observers  not 

comparable,  ii.  386 
stomach  disturbances  in,  i.  257 
suitable  diet  for,  ii.  315 


INDEX 


705 


Tuberculosis — Cont  'd 

suitable  exercise  in,  ii.  298 

swimming  in,  ii.  300,  410 

suspected,    physician's    duty    in,    i. 
396 

symptoms  of,  during  clinical  activ- 
ity, ii.  218 
heart  strain  in,  ii.  290 

technic  of,  applying  exercise  in,  ii. 
295 
artificial  pneumothorax  in,  ii.  434 
using     psychotherapy     in     treat- 
ment of,  ii.  396,  398 

tepid  sponge  in,  ii.  410 

therapeutics  of  inland  climates  m, 
ii.  268 

traumatic,  i.  312 

treatment  of,  depends  on  close  de- 
tail, ii.  222 

treatment  of  neurasthenia  in,  ii.  398 

treatment  of  symptoms  of,  ii.  445 

tuberculin  in,  ii.  329 

usually  advanced  before  diagnosed, 
i.  60S 

valuable  measures  in  treatment  of, 
act  indirectly,  ii.  202 

value  of  study  of  sputum  in,  i.  535 

value  of  temperature    in    diagnosis 
of,  i.  607 

value  of  tuberculin  in  treatment  of, 
ii.  202 

vasomotor  system  unstable  in,  ii.  143 

warm  air  in,  ii.  271 

wasting  in,  ii.  320 

why  difficult  to  cure,  ii.  348 

zones  of  pain  in,  ii.  456 
Tuberculosis  clinic,  ii.  522 
Tuberculous  enteritis,  effect  in   slow- 
ing   pulse,  case    illustrating, 
ii.  654 

muscle  rigidity  in,  case  illustrating, 
ii.  660 

postmortem   findings  in,  case  illus- 
trating, ii.  656 

temperature  curve  of,  case  illustrat- 
ing, ii.   654 
Tuberculous   infection,   danger   of,   i. 

504 
Tuberculous   meningitis,  bromides  in, 
ii.  91 

case  illustrating,  ii.  94 

ice  cap  in,  ii.  91 

symptoms  of  appear  before  recog- 
nized, ii.  94 
Tuberculous  patient,  and  suggestion, 
i.  156 


Tuberculous  patient — Cont  'd 

association  with,  in  auult  life  of  lit- 
tle danger,  i.  363 
does  not  differ  from  non-tubercul- 
ous in  physique  or  form  of 
body,  i.  363 
easily  duped,  i.  155 
factors  making  open  air  valuable  in 

treatment  of,  ii.  258 
suspiciousness  of,  i.  151 
temperature  in,  easily  influenced,  ii. 
123 
Tuberculous     pericarditis,    pathology 

of,  i.  49 
Tuberculous     peritonitis,     effect     of 
operation  on,  i.  50 
pathology  of,  i.  50 
Tuberculous  pleurisy,  pathology  of,  i. 

48 
Tuberculous  process,  activity  in,  i.  26 
per   se   early   symptoms   due  to,   i. 
366 
Types  of  individuals,  classification  of, 
i.  354 
mixed,  characteristics  of,  i.  351 


Ulcer,  tuberculous,  i.  27 

Underfeeding  and  tuberculosis,  ii.  314 

Urinary  system,  muscles  of   supplied 
by  sympathetics,  i.  176 

Urine,  bunching  of  bacilli  in,  i.  574 
collection  of  specimens,  i.  568 
condition  of,  and  prognosis,  i.  639 
diagnostic  and  prognostic  value  of, 

findings  in,  i.  585 
diazo  reaction  in,  i.  569,  585 
examination  of,  i.  5f'8 
indican  determination  in,  i.  572,  586 
in  tuberculous  kidney,  ii.  98 
technic  of   examining  for  tubercle 

bacilli,  i.  575 
tubercle  bacilli  in,  i.  574 
urochromogen  in,  i.  575,  585 
value  of  24  hr.  specimen,  i.  568 

Urochromogen,     and     diazo     reaction 
compared,  i.  571 

Urochromogen  reaction,  i.  570 
and  prognosis,  i.  639 

Urochromogen     test,     standardization 
of,  i.  572 

Urticaria,  due  to  anaphylaxis,  ii.  157 


706 


INDEX 


Vagotonia,    inherited,    illustrated    in 
hay  fever,  ii.  162 
marked,  case  illustrating,  ii.  584 
Vagotonic,    asthma    occurs    in    those 

naturally,  ii.  166 
Vagus,  greater,  action  of  may  be  se- 
lective, i.  174 
and  digestive  tract,  i.  254 
characteristics    of,    action    in,    i. 
227 
peculiarities  of,  i.  170 
peripherally  irritated,  causes  re- 
flex symptoms,  i.  604 
structures  supplied  by,  i.  175 
system,  i.  170 
stimulated  by  pulmonary  inflamma- 
tion, slows  heart,  i.  231 
tonus,  asthma  indication  of,  ii.  164 
indicated  in  slow  pulse,  ii.  551 
in  digestive  tract,  i.  440 
,  shown  in  puise,  case  illustrating,  ii. 
584,  618 
Vaso  dilatation,  part  of  syndrome  of 

toxemia,  ii.   110 
Vasomotor        disturbance,       marked, 
causes  increased  diurnal  vari- 
ation in  temperature,  case  il- 
lustrating, ii.  646 
Vasomotor     equilibrium,     disturbance 
of,  ii.  121 
in  severe  toxemia,  ii.  139 
Vasomotor  system,  unstable  in  tuber- 
culosis, ii.  143 
Vaughan,  contributions    to    study  of 
fever,  ii.  113 
discussion  of  protein  fever,  ii.  118 
produces  various  types  of  fever  arti- 
ficially, ii.  114 
tuberculin  reaction  and  anaphylaxis, 
ii.  341 
Vegetables,  carbohydrate  value  of,  ii. 

320 
Vegetarianism,  ii.  309 
Vegetative  nervous  system,  i.  169 
and  anaphylaxis,  ii.  157 
relation  of  symptoms  to,  i.  183 
statement    of    terms    used,    i.    170, 
186 
Vegetative    system,    antagonistic    ac- 
tion   of    greater    vagus    and 
sypathetic     divisions     of,    i. 
187,  198,  384 


Vegetative  system — Cont  'd 

cells  of,  travel  out  from  the  central 

nervous  system,  i.  170 
connection  with  central  nervous  sys- 
tem, i.  170 

Ventilation,  poor,  produces  ill  effects, 
ii.  246 

Veratrum  viride  in  treatment  of  hem- 
orrhage, ii.  178 

Vincent,  Swale,  internal  secretions,  i. 
169 

Viscera,  no  single  type  of  form,  posi- 
tion or  function  for,  i.  337 

Visceral  function,  normal  variation 
in,  i.  333,  335 

Visceral  nerves,  inhibitory  action  in, 
i.   174 

Vocal  fremitus  in  pneumothorax,  ii. 
80 

Voice  transmission  over  cavity,  i.  492 

Vomiting,    in    advanced    tuberculosis, 
i.  440 
in  anaphylaxis,  ii.  139 

Von  Behring  and  artificial  immuniza- 
tion, ii.  335 

Von  Leyden,  advantages  of  sanatori- 
um treatment,  ii.  482 

Von  Muralt,  discusses  suspiciousness 
of  tuberculous  patient,  i.  157 

Von  Pirquet,  and  tuberculin  reaction, 
ii.  336 
cutaneous  tuberculin  test,  i.  502,  512 

Von    Ruck,    and    artificial   immuniza- 
tion, ii.  335 
water  extract,  ii.  355 

W 

Walking,  best  exercise  for  tubercul- 
ous, ii.  299 

Walsh,  frequency  of  tuberculous  in- 
fection of  kidney,  ii.  96 

Walters,  advantage  of  sanatorium 
treatment,  ii.  482 

Wassermann  and  Bruch,  suggest  ses- 
sile receptors  in  necrotic 
areas  fully  satisfied,  ii.   348 

Water,  distilled,  contaminated,  pro- 
duces protein  poisoning,  ii. 
179 

Watery  Extract,  von  Euck,  ii.  355 

Wax,  interbacillary,  solvents  for,  i. 
548 

Weather,  psychological  influence  of, 
ii.  261 

Webb,  and  artificial  immunization,  ii. 
355 


INDEX 


707 


Webb  and  Williams,   experiments   in 

active  immunization,  i.  96 
Weber,  discussion  of  climate,  ii.  254 
Weight,  body,  increases  most  in  cool 
weather,  ii.  273 
effect  of  large  increase  in  normal, 

ii.  312 
gain  of,  goes  with  improvement,  ii. 

311 
increases  with  improvement,  ii.  531 
loss  of,  as  result  of  overdoing,  ii. 
532 
due  to  depressive  emotions,  i.  441 
in  advanced  tuberculosis,  i.  440 

compensatory,  i.  441 
part  of  syndrome  of  toxemia,  ii. 
110 
satisfactory  gain  in,  illustrated,  ii. 

562 
seasonal  changes  in,  ii.  293 
Wet   jacket   in   treatment   of    cough, 

ii.  411 
Wet  method  of  preparing  sputum  for 

examination,  i.  556 
Whispered  voice  in  early  pulmonary 

tuberculosis,  i.  434 
Williams,   sign,  i.  524 
Wolff-Eisner,  and  tuberculin  reaction, 
ii.  336 
conjunctival  tuberculin  test,  i.  502, 
515 
Woodhead,  statistics  of  glandular  tu- 
berculosis in  children,  i.  113 
Woodruff,  effect  of  light   of  tropics, 

ii.  426 
Worry,  effect   on  temperature   curve, 

ii.  146 
Wright,  emphasizes  small  doses  of  tu- 
berculin,  ii.    370 


X-ray,   accuracy   and   limitations    of, 
i.  521 


X-ray— Cont'd 

and   physical   examination,  relative 
value  of,  i.  516 

average,    examination    equals    poor 
physical  examination,  i.  611 

can     it     differentiate     active     and 
healed  lesions,  i.  518 

cases  illustrating  reading  of,  plates, 
i.    527,    528,    529,    530,    532 

fluoroscopic,  method,  i.  524 

in  diagnosis  of  pulmonary  tubercu- 
losis, i.  516 

in  early  diagnosis   of  tuberculosis, 
i.  611 

in  spontaneous  pneumothorax,  ii.  81 

limited  motion  of  diaphragm,  shown 
by,  i.  525 

method  of  using,  in  pulmonary  di- 
agnosis, i.  524 

value  of,  in  diagnosis,  i.  517 
X-ray  plate,    cause    of   normal    hilus 
and  trunk  shadows  in,  i.  521, 
524 

interpretation  of,  i.  521 
X-ray   stereoscopic    plate,    and    phys- 
ical   examination    compared, 
i.  526 

cases  illustrating,  i.  527,  528,  529, 
530,  532 

value  of,  i.  524 
Xylol    and    chloroform    dissolve    wax 
and    distribute    bacilli    that 
are  bunched,  i.  549 


Ziehl-Neilsen  stain  for  bacilli,  i.  556 
Zinsser,  tuberculin  reaction  and  ana- 
phylaxis, ii.  341 
Zunst,    Loewy,    Muller    and    Caspari, 
discussion  of  climate,  ii.  255 


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